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LEARNING OBJECTIVES:
1. Discuss differences in instrument quality.
2. Describe the process to correlate surgical set contents with
count sheets.
3. Explain five inspection factors used to select appropriate
instruments.
Instrument Quality
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.
Instrument Set Contents
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
Instrument Selection for Surgical Sets
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CIS Self-Study leSSon Plan
LESSON NO. CIS 219 (Instrument Continuing Education-ICE)
Instrument Continuing Education (ICE) lessons 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.
You can use these lessons as an in-service with your staff, or
visit www.iahcsmm.org for online grading at a nominal fee.
Each lesson plan graded online with a passing score of 70% or
higher is worth two points (2 contact hours). 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 ICE Lesson Plans
is not available through IAHCSMM or Purdue University; IAHCSMM
accepts only online subscriptions).
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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.
Lesson Author
Carla McDermott, RN, ACE, CRCST Educator
South Florida Baptist Hospital, Lakeland, FL
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IaHCSMM CIS Self-Study lesson Plan
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:
the manufacturers name and catalog number (to help with
identification and replacement)
its length and weight the facilitys specific name for the
instrument if it is different from that used by the
manufacturer. Note: The use of unique instrument names can be
frustrating for inexperienced CIS technicians and sharing this
information in the instrument manual or library is helpful.
the number required
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.
Instrument Selection
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:
is of surgical-grade is the same length has identical tips is
matched in weight (examples: Pediatric,
Plastic, General, and Orthopedic)
is in good working order
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.
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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.
Summary
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.
Resources
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.
IaHCSMM CIS Self-Study lesson Plan
Technical Editor Carla McDermott, RN, ACE, CRCST Educator South
Florida Baptist Hospital, Lakeland, FL
Series Writer/Editor Jack D. Ninemeier, Ph.D. Michigan State
University East Lansing, MI
CIS Self-Study leSSon PlanS
IAHCSMM is looking for volunteers to write or contribute
information for our CIS Self-Study Lessons. Doing so is a great way
to contribute to your own professional development, to your
association, and to your Central Sterile Supply Department
peers.
Our team will provide guidelines and help you with the lesson to
assure it will be an enjoyable process. For more information,
please contact Elizabeth Berrios ([email protected]).
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CIS Self-Study lesson Plan Quiz(Instrument Continuing
Education-ICE) Lesson No. CIS 219: Instrument Selection for
Surgical SetsQuestions (circle correct answer):
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1. Surgical-grade instruments are interchangeable with most
floor-grade instruments.
a. True
b. False
2. One advantage to surgical-grade instruments is how long they
last.
a. True
b. False
3. Stainless steel is the same no matter how it is
manufactured.
a. True
b. False
4. Mixing disposable, floor-grade, and surgical-grade
instruments in an ultrasonic cleaner is an acceptable practice
because this saves valuable time.
a. True
b. False
5. Surgical instrument sets should follow a pattern of assembly
determined by the most experienced CIS technician.
a. True
b. False
6. The use of manufacturers catalog numbers makes the reordering
of replacement instruments easier.
a. True
b. False
7. When an instrument is missing, it is important to leave a
note for the supervisor and then sterilize the set as usual.
a. True
b. False
8. Following the count sheet exactly is vital to good patient
care.
a. True
b. False
9. Babcocks are used in bowel surgeries.
a. True
b. False
10. Kochers are used to hold fascia, ligaments and
cartilage.
a. True
b. False
11. The inspection of instrument tips is time consuming and
usually unnecessary.
a. True
b. False
12. Working with the surgical team to select appropriate
instrument sizes provides better patient care.
a. True
b. False
13. Needle holders with TC inserts can create a matching
dilemma.
a. True
b. False
14. Gelpi retractors are handheld retractors.
a. True
b. False
15. The proper processing of surgical instrument sets helps to
ensure quality patient care.
a. True
b. False
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