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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The care and handling of sharp instruments can be challenging, but the task is important because surgeons require them to work effectively. Sharp instruments are used in every specialty; for example; scissors or trocars in General Surgery, tonometers and picks in Ophthalmology, and curettes in Gynecology and Otolaryngology (ENT). Orthopedics and Neurosurgery present even greater challenges because of their extensive use of osteotomes, curettes, rongeurs, kerrisons, and other sharp instruments which dull very quickly because they are used on bone. This lesson addresses basic procedures to safely handle sharp instruments and the important role that Certified Instrument Specialist (CIS) technicians play in keeping sharp instruments in top working condition.
Operating room (OR) staff and CIS technicians handle so many instruments during the day that it is easy to forget their complexity and the care they require. For example, basic Mayo or Metzenbaum scissors are commonly used in many sets, but they should be tested routinely.
Operating room personnel have front line responsibilities to begin the process of protecting sharp instruments. Surgical instruments should be used only for their intended purpose. For example, a heavy scissors should not be used as a “sterile bottle opener” that can damage the instrument and contaminate the sterile contents of the bottle. Scissors should never be used to open boxes or to scrape off color code tape, because this practice can damage sharp edges and weakens the balance of the instrument’s box lock.
All too often sharp instruments used in the OR are piled together with other stainless steel instruments used during the procedure, and their edges may be dulled as they rub against each other. Then if they are placed unprotected in a case cart for transport to the decontamination area, friction that occurs as the cart bounces over uneven floors may further damage their sharp edges.
The recommended method of post-op treatment is to carefully separate instruments after use, and prepare them for transport to the reprocessing area. This is done by assuring that heavy instruments are not placed on top of delicate, sharp ones, and by protecting their sharp edges during transport. Some hospitals have designated baskets for sharp instruments, while others simply separate them on a towel so they are visible, yet protected. Organizing components within the pan can also protect sharp instruments during transportation. Remember to keep instruments moistened between their use in the OR and arrival in the Central Service area to expedite the cleaning process.
CIS technicians wearing personal protective equipment (PPE) should carefully separate items received in Central Service. Accidents can occur as box locks and jaws are opened to enable all surfaces to be effectively cleaned manually or by the washer-decontaminator. Staff must take the time necessary to protect themselves by being alert to the dangers posed by sharp contaminated instruments. Never reach into a set of instruments submerged in water without a clear view of the contents. Ideally, sharp instruments should always be separated from non-sharp instruments, but never assume that this has occurred.
Pay close attention to sharp instrument edges and tips when sets are disassembled for cleaning. Assure that they do not rub against other instruments to avoid damage to delicate sharp edges. For the protection of the staff as well as the sharp items, instruments should be handled individually, not in a bundle. They should be cleaned with nylon brushes and non-abrasive instrument cleaners. Examine the box locks of scissors to assure that no debris remains that could cause friction and eventually cause the instrument to malfunction.
Debris in the box lock may lead to “fretting corrosion” which affects the instrument’s function. This is a result of improper cleaning, and will lead to micro abrasion and, finally, a breakdown of the outer passive layer. Left unchecked and without proper cleaning and lubrication, corrosion and improper function will result.
Delicate scissors should be arranged so their tips are protected when they are manually washed or placed in the washer decontaminator. One effective method is to organize instruments with handles on 5” wide stringers to open their jaws and expose their box locks to water and detergents. The strung instruments can be turned so the tips point upward to expose all surfaces to jets of water as they go through the washer-decontaminator.
Cutting instruments such as osteotomes, chisels, gouges, and bone or gynecological curettes will ideally be stored in devices that protect the tips from rubbing on each other, and that provide protection when they are placed in the washer decontaminator. Small organizational baskets in the washer decontaminator are often necessary for small, delicate items such as picks, fine curettes, or osteotomes used in hand surgery.
Once instruments have been properly decontaminated, functional checks are important to help assure surgeon satisfaction. These checks are important for patient safety as well. For example, dull instruments may tear delicate tissue during a procedure. General testing guidelines include visual inspection of the instrument’s surfaces. They should be clean, smooth, and without crevices, rough spots, or grinding marks that provide an opportunity for corrosion and that can harbor bacteria. Instrument tips, blades, handles, box locks, alignment, and working mechanisms should be carefully examined.
Specific testing procedures are used for different sharp instruments, and some examples follow. It is important to remember that running your finger over sharp edges is never recommended.
Scissors. To test micro or full-size scissors for sharpness and proper alignment, cut a latex glove or test material from the mid-point of the blades to the distal end. The scissors should cleanly cut the latex or test material without grabbing or “chewing” it between the blades. Note: scissors in poor alignment will not cut smoothly, and the latex will “bunch up” as the test is performed. Another way to test scissors for alignment is to hold them up to light and, while closing, confirm that the blades contact only at one point on the lead cutting edge of the scissors. This indicates that a proper helix curve exists on the opposing blades, and it will assure that the surgeon can control the scissors. To test for tightness, lay the scissors flat on a table, and look from the rings towards the tip. If the left shank is higher, the scissors are too loose. If the right shank is higher, they are too tight.
To test the “set” or tightness of the box lock, open the scissors and, while holding onto the bottom ring and shank horizontal to the floor, drop the top ring. The blades’ distal tips should remain 1/2 to 1/3 open. If the blade closes completely, the scissors are too loose. If it closes less than halfway, the scissors are too tight.
Trocars. The cutting edges of trocars should be sharp, and they should not be ground too short by excessive sharpening. They should be visually examined for burrs and/or gouges on their cutting edge.
Osteotomes. Osteotomes should be visually inspected, and those with obvious nicks or gouges should be removed from service. Tests include scraping them on an angle against a plastic dowel rod which should shave tiny pieces of plastic from the rod.
Rongeurs. A properly sharpened rongeur should cut a business card cleanly or leave an even indentation. Close the distal 1/3 to 1/2 of the cup onto a business card. Note: if a thick business card is used, a clean cut may not be achieved, but an even indentation will indicate a sharp instrument. Double action rongeurs should be free of play in the shanks and jaws.
Kerrison Rongeurs. Squeeze (close) the Kerrison handle and assure that the action is smooth with no grinding or catching. When closed, the moving shaft should touch the foot plate, but it should not travel so far as to cause stress to the foot plate. The handle should spring back quickly when released. If it does not, check to assure the instrument has been properly cleaned and lubricated. Also, confirm that the spring is in place, and that there are no cracks in the spring, especially where the screws secure the spring. Assure that all the screws are in place and are firmly seated. Hold the Kerrison up to the light in the closed position. If no light shines through the jaws, this means the jaws meet correctly.
Intervertebral Disc Rongeurs. Disc rongeurs should grasp a hair firmly and cut it cleanly. The jaws should meet precisely, and they should always be sharpened from the inside of the jaws (not ground or filed from outside) to maintain proper cutting alignment.
Curettes. Visually check the cup’s surface. Its profile should be flat across the top without nicks or gouges. A properly sharpened curette, when scraped against a piece of plastic dowel, should plane off “ribbons” of plastic.
Do not “pour” clean instruments from a tray or basket onto hard metal surfaces when assembling them. Instrument tables should be protected with towels or mats to prevent damage caused by metal rubbing on metal. Many supplies are available to help protect instruments during assembly and when they are in containers. For example, silicone mats (some with fingers and others that are more open) are available for the bottoms of instrument baskets. Paper pockets approved for steam penetration may protect instruments if multiple instruments are not “jammed” into a single pocket. Placing instruments carefully in the basket without crowding and the use of protectors for delicate tips should help assure that instruments are packaged in a way that allows steam to penetrate while instruments are protected.
Many container companies provide organizing devices for instrument baskets to protect sharps. Upright pins placed in the bottom of the basket provide one method of organizing and protecting sharps while a large variety of positioning racks and fingers are another very effective mechanism for protection.
These same devices for organizing instruments can also serve to protect staff from sharp instruments floating in sets.
Following set assembly, CIS technicians should carefully place instrument sets onto sterilizer racks and assure that the instruments are not jostled while the sterilizer is loaded. Concerns applicable to carefully moving instruments from the point-of-use to Central Service areas also apply as sets are placed into storage, loaded onto case carts, and transported to usage areas. This requires that sets and/or containers not be bounced over uneven floors during transportation.
Properly maintaining instruments during daily use is a key to keeping instruments in top working order. A quality repair/refurbishment plan is also essential. Then, as instruments become dull with routine usage, a qualified instrument specialist can bring them back to peak condition. Ideally, an instrument management system will alert CIS Technicians to the need for periodic maintenance of sharps. At the minimum, a manual system for instrument maintenance may be used to manage routine sharpening. Whatever system is in place, knowledgeable and alert staff should pull instruments that show wear from sets as they are being assembled.
The quality care of sharp instruments lies in the hands of competent CIS technicians. Their attention to detail with routine checks and instrument maintenance procedures will help assure that safe and high-quality instruments are in the surgeons’ hands so patients can have the best possible outcomes.
For general information about Central Service safety concerns including those applicable to sharp instruments, see:
1. Managing Safety Hazards in Central Service. Exx Cel 2000 Plus: Strategies for Success. (Manual Six). International Association of Healthcare Central Service Materiel Management. 2000.
2. Central Service Technical Manual. Seventh Edition. Chicago, Il. International Association of Healthcare Central Service Materiel Management. 2007.
Peggy Pittenger, RN, CRCST
Materials Management Microsystems
Carla McDermott, RN, ACE
Clinical Nurse 3
South Florida Baptist Hospital t
Plant City, FL
Jack D. Ninemeier, Ph.D.
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI.