Surgical Instrument Care in Sterile Processing
General Guideline to Quality Issues - Root Causes and Prevention
Surgical instruments are one of the most significant financial investments for healthcare facilities. Proper care should be considered to prolong their useful life and ensure their correct clinical use. Functioning instruments for patient cases enables the Operating Room to perform procedures and generate revenue. A compromised instrument is often a root cause of delaying or even canceling surgical cases.
Having proper quality procedures in place helps to preserve the surgical instruments and avoid financial implications of delayed surgeries. Additionally, educating the OR and SPD staff on preventing instrument damage from improper reprocessing processes can significantly minimize instrument rejection in the OR by Surgical Staff. These practices ensure the smooth operation of the OR and patient satisfaction.
Start at the beginning – the Operating Room
Reprocessing of the instruments used in surgical procedure begins with the immediate removal of gross soil to stop the pitting and corrosion process, as well as biofilm formation, as shown in Figure 1.
If the following steps are not implemented, surgical instruments may experience harm to their passivation layer and become stained or permanently discolored.
- Instruments should be kept moist during the instrument transportation process.
- Always use the approved pretreatment products, follow your facility instrument prep, and transport guidelines.
- Once in the SPD, follow the department Policies and Procedures to complete the manual and automated cleaning and disinfection processes.
(Never soak instruments in harsh solutions such as saline, as this process will inadvertently harm instruments. The use of sterile water is a much better alternative.)
Examples of instrument quality issues and how to address them:
Take the appropriate steps when the issue occurs. Always start investigating the problem with a root cause analysis. Reach out to your instrument, equipment, and chemistry vendors for help. Work with your facility management team to determinate the quality of water used in the decontamination process.
Pitting and corrosion
Pitting and corrosion occur when the instrument’s passivation layer gets damaged due to improper handling or reprocessing.
The leading cause of damage to the instrument’s “safeguarding” layer is harm done by exposure to inappropriate solutions of “aggressive” cleaners with highly alkaline and acidic characteristics. This can leave them vulnerable to scratches on the surface. The scratched area develops pitting that is now prone to develop corrosion of the material, which results in deterioration due to oxidation from air exposure.
When observing any scratch (regardless how small), remove the instruments temporarily from use and work with your local refurbishing vendor to repair them. If such a practice is not implemented, the affected instruments may be subject to further damage of the passivation layer, making it more prone to corrosion attack.
The damage is often irreversible, and the instrument must be removed from use. An example of irreversible damage is shown in Figure 2.
The presence of the denatured, baked, or dried bio-soil is often mistaken for the presence of rust on the instrument's surfaces. Dry blood stains are also brown-orange, as shown in Figure 3.
Use a standard pencil eraser to determine whether it is rust or a stain on your instrument. Rub the eraser into the mark. If the discoloration is removed and the metal underneath shines, this indicates the presence of a stain. If a pit mark appears under the discoloration, this points to rust and must be addressed.
Other factors that can damage the surgical instrument's passivation layer are caused by water quality - hardness, high chloride content, and extreme high or low pH.
An excellent preventive measure is to partner with your facility's water management team and implement frequent water quality checks, implementing corrective actions when it does not meet required quality levels.
Spotting and Staining
Speaking of water, water quality used in decontamination processes can often cause spotting and staining of surgical instruments.
Attention should be paid to regular maintenance of the water treatment process to eliminate organic and inorganic content from the final rinse that may cause spotting and staining on the surgical instrument's surface and may sometimes present itself in the washer chambers shown in Figure 4.
Many facilities are affected by the high silica content in their water. Elevated concentration causes the formation of the "snakeskin" pattern on the surface of the surgical instrument, as shown in Figure 5.
Another common mistake facilities make is the use of cleaning solutions outside the recommended dosing range or incorrect dilution rates.
- Train your staff to periodically check the manufacturer IFU’s for proper detergent use.
- Work with your equipment vendor’s Service Team to maintain and calibrate medical equipment, so it doses the appropriate amount of the chemical.
- Residues of cleaning solution can stain and discolor surgical instruments if they are not rinsed adequately. Add a rinse step if needed.
Steam Quality is also a key driver of instrument quality. Pay attention to your sterilizer steam. When surgical instruments are exposed to contaminated steam, they often become multicolored, as shown in Figure 6.
Test the steam to ensure it is meeting the steam quality requirement and double-check the manufacturer's guidelines for sterilization. If the issue persists, contact the medical equipment vendor.
In Summary
There is no instrument sterile processing operation that is not challenged periodically with Instrument staining, rusting, or residue issues, but when they occur, know how to react by:
- Establishing and ensuring proper protocols are being followed.
- Establishing Troubleshooting guidelines to aid in timely resolution.
- Providing Proper training to your team on what to do when you see these issues.
Good surgical reprocessing practices and rigorous training are the best prevention to maintain high surgical instrument quality and avoid issues.
According to ANSI/AAMI STD 79, the medical facility must “use good quality water to rinse instruments whether they are cleaned manually or mechanically and always use DI water in the critical rinse, before sterilizing processes.”
Always reach out to your suppliers of chemistry, equipment, and instrument repair for help.
About the Author
Barbara Choczaj is a Senior Technical Manager and Scientist at Belimed with 18 years of experience developing high-performing products for reprocessing medical devices and helping Sterile Processing Professionals achieve industry standards by providing technical assistance. She holds a degree in Master of Science in Chemistry and is Six Sigma Green Belt Certified.