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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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Lesson Plan CIS 216
Creating and Maintaining Correct Instrument Sets
[Reprinted from Communiqué: November/December 2009]

There are, seemingly, innumerable surgical instrument sets used everyday in healthcare surgical suites. The processes required to develop and maintain them are vital to the success of every surgical team and are among the critical responsibilities of Certified Instrument Specialist (CIS) technicians. Developing the correct configuration of specific instruments in the correct quantities requires considerable thought and significant input from a variety of surgical
team members.

Many questions must be asked as new sets are developed and as existing sets are maintained and utilized. How are surgical instrument sets developed? Who is responsible for their development? How are they evaluated and updated? These are among the questions to be addressed in this lesson to help CIS technicians consistently ensure that the instrument sets being used are the “right” ones for their facility.

Why, with all the instrument sets currently used in most healthcare facilities, must new sets be developed? One common reason is that new surgeons may provide services not previously offered, and/or they may prefer to use new or different instrument sets for currently offered medical services. Surgeons are customers of the hospital, regardless of whether they are employees or self-employed. Like CIS technicians, nurses and other staff members, they may move from one hospital to another.

Gathering this information can be troublesome, but a variety of techniques may be used. Meetings between new surgeons and the Central Service leadership team can help identify their set preferences. Also, every facility uses instrument count sheets that outline the exact type and number of instruments in a specific set. Obtaining count sheets and preference cards used by new surgeons at their previous hospitals is an excellent way to establish a baseline for their needs. This planning and preparation is needed to prevent the delays and frustrations that can otherwise occur when instrument sets are distributed for initial use in surgical procedures by new surgical personnel.

Existing surgical staff may also begin to offer medical interventions for which new instrument sets must be made available. The same protocols noted above, including detailed discussions to learn about the required content of instrument sets for these services, are important. Review of instrument count sheets used by other facilities where the new surgeries are performed—and from applicable instrument vendors—can be very beneficial.

In today’s fast-paced world of healthcare, surgical procedures can change very quickly. Consider, for example, changes that occurred in the mid-to-late 1980s, when laparoscopic surgery became the technique of choice to perform cholecystectomies (gall bladder removals). Traditional open surgical techniques required instrument sets containing the typical hand-held instruments used for cutting, grasping and suturing. In contrast, laparoscopic surgery required vastly different instrument sets containing new devices to support these new techniques.

After instrument sets are initially developed, an ongoing assessment process will ensure that the sets address the surgeons’ and the facility’s current needs. Although an existing set may be used extensively, certain items within the set may not be used, while others might be needed to meet current demands.

Continuous assessment and communication must occur to properly develop and maintain the facility’s inventory of surgical instruments. Effective written and/or oral communication with end users is essential for this to occur. The required input for set maintenance must be generated from surgical team members, including nurses, surgical technicians, surgeons, CS managers, CIS technicians, and facility administrators. Surveys, e-mails, and interviews involving those from each of these specialties will be very helpful. The result will be different perspectives useful in determining the necessary types and number of instruments, along with their quantity, set configuration (how tray contents are arranged), maintenance, packaging and sterilization requirements, and associated costs.

A note of caution: interviews, meetings and other discussions require a good memory and carefully constructed notes and files to help ensure that nothing is forgotten or misunderstood. Unfortunately, sometimes promises are made, but not fully delivered, which may yield decreased customer satisfaction.

Communication in Action

Numerous tactics can be included in a planned and organized communication program to educate customers about and learn their exact needs for instrument sets. Many examples are used during a month-long instrument fair at the Greater Baltimore Medical Center. Surgeons receive e-mail announcements from the facility’s Surgical Services Director and Medical Director, and signs are posted throughout operating room areas. Note: The length of time for the fair is based on the size of the facility’s instrument inventory and the types of surgeries it offers. The instrument fair features different surgical specialties on specific days that are scheduled well in advance. CS technicians help set-up, organize, gather information, and return items to inventory at the completion of each day during the instrument fair.

For example, on the day of the Orthopedic Fair, items applicable to orthopedic surgery —including instrument sets and individual items, such as retractor sets and power equipment—are displayed, as are items currently included on count lists that are rarely, if ever, used. Advance notices are sent to orthopedic OR team members and surgeons inviting them to inspect and assess the facility’s current instrumentation available for this surgical specialty. Instrument set lists are displayed with the instrument sets, and opinion sheets allow the attendees to provide written comments about the accuracy of each set. CS personnel greet the visitors as they enter the display area and walk with them as they view the displays.

Orthopedic team members and surgeons are encouraged to make oral and written comments about whether:

• Each set meets current needs.
• Any set should be removed from service.
• Items should be added to or deleted from each set.
• The current quantity of sets is adequate to meet demand.
• The quality of instrument maintenance meets their needs.

During each specialty fair, CS professionals provide information about the required number of trays needed daily, based upon their experience with requests made for the trays. This provides an opportunity for surgeons, OR and CS staff to discuss the challenges encountered when turnover requests permit only minimal processing time. For example, CS professionals discuss required decontamination protocols and the advantages and disadvantages of flash sterilization as an alternative to preferred sterilization methods. Note: The Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI) recommend that flash sterilization only be performed when absolutely necessary or in an emergency situation.1 Neither organization supports flash sterilization of implant sets. CS personnel also explain the lack of approved validation for flash sterilization from loaner orthopedic and spine set manufacturers based on receipt of current instructions from manufacturers. This discussion may prompt physicians and other OR staff to express the need for additional quantities of applicable instruments in an effort to avoid flash sterilization.

After the instrument fairs are completed for each surgical specialty, comments are documented and action plans are developed to address improvements required for each specialty. The action plans address specific needs, and they provide helpful information to develop a comprehensive and prioritized list of capital and operational budget requests. This will help build and maintain instrument inventories to meet the needs of surgical customers.

Ongoing Maintenance Required

After components of instrument sets are agreed upon and new sets are created, procedures for their continuous assessment and maintenance become important. Without this emphasis, the efforts required to develop the ideal instrument sets will be wasted because of changing needs that can often occur very quickly. It is very important that the recommendations of each instrument manufacturer be obtained and studied. These recommendations describe routine maintenance, lubrication and cleaning techniques, along with sterilization instructions. Failure to follow these instructions can lead to damaged equipment or shortened instrument life. The perfect set of instruments, based on customers’ recommendations, will not be satisfactory if they are supplied with devices that are rusty, dull, broken, or unsterilized. Reliable and professional service provided by the CS processing team will go a long way in reducing or preventing frustration for
end users.

It is important to plan, implement and maintain an effective repair and maintenance program for all instrument sets. Mobile instrument repair vendors may be able to repair devices on-site, but complete refurbishment will likely require sending sets for off-site service. Instrument repair vendors must be carefully chosen because their work impacts the ability of CS technicians to deliver what they promise: the availability of the appropriate instruments properly processed in the correct number, and in the required working condition.

Finally, it is important to recognize the importance of developing and maintaining an appropriate budget to support the facility’s surgical instrument inventory. Funding will be required in both the capital budget (for purchase of new instruments) and in operating budgets to maintain existing instruments. The amount required differs for each facility and will be based upon numerous factors. These include the introduction of new technology, changes in the volume of certain specialties, and the extent of repair and replacement required for existing inventory items.

Most instrument manufacturers and vendors can provide an average annual cost of repair and replacement, based on specific inventory volumes and usage intervals that can be used as a benchmark for a facility’s specific budget estimates. Involving facility administrators throughout the entire process of instrument set determination and maintenance can be very helpful when funding must be requested. Those who understand the importance of developing and maintaining the proper instrument sets based on surgeon and staff needs are more likely to offer the needed support.

In Conclusion

This lesson has explored ideas helpful in developing and maintaining surgical instrument sets. It is important to have the proper number of necessary instrument sets, with the proper quantity and contents of instruments within each set. Additionally, an effective repair and maintenance plan, along with appropriate funding, is needed to support the demand for surgical instruments.
Still, the most vital element in the management of instrument sets is a good working relationship with—and effective communication amongst—surgeons, OR staff, and CS personnel. With these components in place, challenges relating to surgical instrument sets will be minimized, and healthcare facility personnel, including CIS technicians, will be able to focus their activities on ensuring that patients’ needs are consistently met.

References:

1. AORN Standards & Recommended Practices: Recommended Practices for Sterilization in the Peri-Operative Practice Setting. 2008, pp. 575-598, and ANSI/AAMI Standards ST79:2006, Sections 1-2, pp. 2-3.

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