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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Surgical Services is the largest volume customer of Central Sterile Supply Departments and the need for accuracy in assembling required instrument sets cannot be over-emphasized. Thousands of instruments pass through the hands of knowledgeable Certified Instrument Specialist (CIS) technicians each week. Their skills in processing and maintaining instruments have a direct impact on the quality of care each surgical patient experiences. This lesson highlights the skills necessary for the appropriate selection of instruments for basic surgical sets.
Surgical-grade instruments are required in all surgical sets because they are designed and manufactured to strict specifications from high-quality stainless steel. They are subjected to quality control inspections at several points during the manufacturing process. These instruments are less likely to fail after repeated uses and should cause no tissue damage related to their construction and finishing. Surgical-grade instruments, if properly handled, cleaned and sterilized, will provide years of useful life. In contrast, floor- (lower) grade instruments may have a similar design, but their specifications for steel quality and manufacture are less stringent. For example, on inspection of new instruments, one may discover nicks and burrs, and instrument tips and jaws may not meet perfectly. Using these instruments in a delicate surgical procedure can lead to unintended tissue damage that, along with the need for tissue repair, increases the potential for poor healing, infection and increased recovery costs.
Disposable and floor-grade instruments should not be placed in an ultrasonic cleaner or surgical sets with surgical grade instruments because doing so can cause metal changes due to ion transfer. These changes, in turn, alter the reaction between the metal and chemicals used for instrument cleaning, disinfection and sterilization. Resistance to staining, pitting and rusting can also be compromised. Once these problems occur, even surgical-grade instruments can be compromised, and they will no longer be appropriate for use in surgical instrument sets.
Knowledgeable CIS technicians effectively manage instrument flow and correctly handle instrument sets to maintain their high quality. Their education and skills protect patients and the significant financial investment made by their facility to have surgical-grade instruments available.
Contents of instrument sets are usually determined by the surgical team. Input about the type and number of each instrument to be available in designated sets is generated from the surgeons, surgical team members and operating room managers. The names and numbers of instruments used in specific sets vary between facilities. Examples include “biopsy set,” “plastic set,” “minor set,” or “soft tissue” sets that include all basic instruments to perform a breast biopsy, inguinal hernia, or other small (shallow) procedure. The specific set name and number of instruments it contains is not important. The ultimate concern is to provide the customer (surgical team) with what is needed in a timely manner.
Trained CIS technicians can assist in gathering specific information for each set and the instruments it contains. They should also follow a written process describing required procedures when an instrument is damaged or missing. It should include details about who should be notified, how replacements are obtained, who should be notified if a replacement is not immediately available, and whether the set can be packaged and sterilized without the missing item. When an incomplete set is approved for sterilization, it must be labeled so the user knows about the missing instrument before the surgical procedure begins. For example, the instrument may be critical for a specific procedure or surgeon, but not for all procedures or surgeons.
CIS technicians processing instrument sets should have the following information available for each instrument in the set:
Instrument set count sheets are created from the above information. Instruments are typically listed on the count sheet in the order the surgical team expects them to be assembled. This promotes continuity and allows the operating room team to quickly count them. Therefore, when stringers or pin trays are utilized, instrument assembly should follow the count sheet order. The surgical team depends on the consistent assembly of sets to streamline surgical procedure set-up and preparation.
A typical order of instruments requested by the surgical team might be as follows: Criles – Kellys – Allis – Babcocks – Kochers – scissors – needle holders – sponge sticks. This set-up should be consistently followed unless a formal change is agreed upon.
Over time, requirements about the types and numbers of instruments in a set may change. They can be suggested by surgical or CSSD personnel, but changes should be approved by a consensus of both departments. Instrument set changes should also be approved by supervisors and/or managers from both departments, especially if instrument budgets will be impacted by the proposed change. For example, the purchase of all gold-handled needle holders for use in every set might be the dream of all the OR team members, but not a viable option for the managers. Information must be shared with all team members in both departments before any change is made, documented on the formal count sheet, and then implemented. It is also helpful to destroy all previous versions of the changed count sheet to avoid any “communication problems.”
The determination of instruments for a surgical set involves making selection choices, unless the count sheet is driven by instrument catalog numbers. While the catalog number method assures exact selection of identical instruments, the potential for changing purchasing contracts may make this method impossible or, at best, inefficient. Alternately, CSSD personnel frequently use some key selection factors to ensure that each type of instrument:
Another issue concerns the relative size of different instruments. For example, when using a 7” scissor, a 7” needle holder and 7” forceps should also be available. Needle holders should also match each other if two like sizes are requested in the set. This becomes a challenge when mixing newer and older needle holders. One little-suspected concern involves matching needle holders with tungsten carbide (TC) inserts. Rejuvenating needle holders by replacing the TC inserts also requires smoothing the newly joined edges, and this removes a minimal amount of the original needle holder jaw/tip. Over time, a Mayo-Hegar needle holder with TC inserts may have a tip that resembles a vascular needle holder. The catalog number may indicate a Mayo-Hegar needle holder, but it does not match a newer instrument. Working with the surgical team, appropriate placement for this usable needle holder can be determined. Then suitably labeling the individual instrument will assist in proper placement each time it is processed.
Several lengths of the same instrument may be requested to provide the surgeon with an appropriate working length instrument throughout the surgery. For example, longer needle holders and forceps work well in deep body cavities, but they can be cumbersome when closing the fascia layer or skin. For this reason, thumb and tissue forceps in three lengths are not uncommon for a major abdominal set. CIS technicians know that it is important to provide matching length pairs when pairs are requested.
The matching of instrument working tips is important to surgeons. The photos that accompany this lesson demonstrate differences in several instruments. Technically, they are all known as Babcocks. However, they are of different styles or from different manufacturers and, while the differences may seem insignificant, they can have a detrimental effect on human tissue. Notice the difference between the Babcocks that are shown.
Babcock forceps are used to hold bowel tissue. These are not a matching pair.
Notice the differences in length, weight, and width of gripping surface.
The clamp is used to securely hold bowel tissue during a bowel resection, and the repair can be hindered if the tips do not match because the tissue can slip when unequal grasping pressure is applied to all edges. Then a slip from this clamp could cause bowel contents to be spilled in the abdominal/peritoneal cavity, and this contamination may cause an infection that increases pain, healing time, and expense for the patient. Allis and Kocher clamps offer a secure hold on tissue when traction (pulling) is required. When used in pairs, if one tip has a smaller bite or fewer teeth, it can tear or slip off the tissue. Human tissue damaged in this way does not heal well, and once again patient care has been compromised.
Kochers are used to hold fascia, ligaments and cartilage. These are not a
matching pair. Notice the differences in length, weight and size of teeth.
Retractors are vital in providing adequate working space and visualization of the operative site for the surgeon. The availability of matching sizes and styles helps meet their needs while protecting the tissue that is retracted. To hold the incision open, equal forces of traction and counter-traction applied by either handheld or self-retaining retractors are required. If the retractor blades or points do not match, tissue damage can result, and tissue healing problems can occur. Retractor blades must, therefore, be inspected for damage.
Handling and packaging procedures are important in properly maintaining surgical instruments. Nicks or burrs along blade edges can tear the tissue needed to heal incisions. Retractors with pointed tips also require inspection for burrs and broken tips.
Note: Gelpi self-retaining retractors are used to hold an incision open to expose
the operative site. These are not a matching pair. Notice the differences
in size and curvature.
This kind of damage is more often caused by mishandling than misuse. Gelpi retractors are self-retaining, and they are frequently used in pairs. When they are, their length, handle width and blade curvatures must match or unequal pressure will be applied to the incision lines. If one tip is broken, it will not hold in place, and the instrument will slip across the cut edge of the incision. Damage to adipose (fat) tissue can result and impair wound healing. Skin hooks are handheld pointed retractors, and they provide another example of the importance of inspection. If their points do not match or if the tips are damaged, they can puncture the skin, and compromised skin edges do not heal smoothly. These examples should confirm that even the simplest surgical instruments require thorough and accurate inspection.
Efficiency and speed can save lives in the operating room. A CIS technician does everything possible to ensure that the correct matching instruments in good working order are available when needed. Teamwork between the users and CIS technicians will help ensure a consistent work flow. Dedication of everyone on the healthcare team helps to ensure the patient has the best care and outcome possible from their surgical experience. As a member of this team, the CIS technician truly is instrumental to patient care.
Central Service Technical Manual. Seventh Edition. Chicago, IL. International Association of Healthcare Central Service Materiel Management. 2007.
Lind, Natalie. Instrument Specialist Course. Identification, Handling, and Processing Surgical Instruments. Chicago, IL. International Association of Healthcare Central Service Materiel Management. 2005.
Loo, V. and McLean, P. ASC Surgery: Principles & Practice. Infection Control in Surgical Practice. 12/2005.
Surgical Technology for the Surgical Technologist. Delmar Thompson Learning. ISBN-10: 0766872921.
The author wishes to thank Clif Morley, CRCST, at South Florida Baptist Hospital, Plant City, FL, for his assistance in preparing the photos used in this lesson.
Carla McDermott, RN, ACE
Morton Plant Mease Healthcare
Carla McDermott, RN, ACE
Morton Plant Mease Healthcare
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI