surve 3 questions

[anna m grayson]

How many of your ORs restring the instruments after surgery?

How many of your OR's send instruments back to decontam "in a neat and orderly fashion "if the OR does not restring?

How many CS/SPD managers would like to have the instruments returned to decontam. on stringers?

I would appreciate any and all feedback.
Thank you!

[djw]

we have 8 or rooms, no one restrings.
all of our dirty instr. come back in decontam containers in solution.
all other instr. are left in the correct trays.

[Uprooted Scrub]

Our OR does not restring, or even put instruments in containers in some cases. Sets are not sorted out into their containers when they're returned.

I do not see the point in having instruments restrung since the process at this facility is to inspect each instrument for visible soil (for an enzymatic soak and hand wash) prior to the instruments going into the washer-decontaminator.

HAve a good day.

Blaine

[jrc]

No, no, and yes!

[SHIRLEEN VANOCKER]

our O.R. does not re-string, and I wouldn't want them to, as we inspect each item and process everything thru decontam. I would, however, appreciate it if the O.R. at least didn't send everything in a jumbled mess!

[cpdguy]

Anna, contact me off line on this subject. Thank you

[anna m grayson]

Thank you all for your input.
cpd gUY,
I tried to email you several times but kept getting returned mail.
Can you contact me at anna.grayson@jeffersonhospital.org?
Thanks

[CSS TECH]

Anna, contact me off line on this subject. Thank you
Cpdguy, I think you are taking away possibilities from people to get educated here by asking so many times for people to contact you off line. I understand when you want to be contacted off line regarding other subjects of economic interest. You have to help the company you are working for make money, but a subject like restringing instruments has nothing to be discussed secretly. That's my opinion!

[CSS TECH]

our O.R. does not re-string, and I wouldn't want them to, as we inspect each item and process everything thru decontam. I would, however, appreciate it if the O.R. at least didn't send everything in a jumbled mess!

You inspect in decontam? I don't get it!

[David Freeman]

Decontam is the best place to find out if things are missing, broken or if there are stowaways that don't belong. Besides, when you disassemble instruments for cleaning, don't you look at them?

[CSS TECH]

Decontam is the best place to find out if things are missing, broken or if there are stowaways that don't belong. Besides, when you disassemble instruments for cleaning, don't you look at them?

I totally disagree. The place where all those activities are to happen is Assembly. Why should I look at instruments when I disassemble them for cleaning? If anything is broken, the OR will attach a tag to it to indicate it's broken. I don't know how you CPD is set and works, but it would be nice if you could share with the rest of us about how your department functions.

[Uprooted Scrub]

I disagree, CSS...the very first step in deconting anything is a visual inspection - dried on crusties will need more than a run through the washer <smile>...why not have the people in decontam give the instrument a quick once over for servicability at that time too??

Have a great day.

B

[cpdguy]

Thank you for the kind words.

I will do my best to clarify.
Being on the "dark side" now I am trying not to talk about products in my answers; you are correct that can be difficult at times. I struggle with that but am getting better.

On the stringing issue; sadly to say I have been working on an article for at least six months and can say I am getting closure to getting it published. Because it is not published yet, and for reason that are longer than you can think of; I did not think it would be this long to complete and send it in. I elected to share the article with two person to help them out. the feed back I have gotten is; I better get off my butt and get it published; these two people said it had a lot of good information. So I am working on it quickly.

I will really work hard on not trying to share off line and make my responses as none commercial as possible. I should be able to do that.

An example would be....On stringing this is one of the most important function that can take place in making sure the surgical instruments are exposed to both cleaning solutions and rinsing process. Their is a lot of support for this process in many publications mostly instrument manufactures care and handling. I can supply some of that information off line if you would like. So please contact me.

The question remains should it be done by the OR staff an/or done is CS. That is an issue that has to be solved by each medical facility because their are many factors involved;one being space and the time it takes to get the items to the decontamination area. what I call the DHT ( decontamination holding time). This is the old issue on how instruments are returned back to CS. We all know this is a concern and stringing helps;it can make the user of the instruments at the point of use be more careful when sending back instruments. If they have to be re-strung ( is that a word ,re-strung ?) again, it is a change in process and change is not easy.

What is the best way. I am person who feels stringing is the way to go.
You can still count them,it has been done. But and this is a big but, it all depends on where you work;space,support.lots of factors....hope this response to this question is better.

Their are products that can help in that process and people need to see if those products fit into their work practice.

Helping you Keep it Clean.

[CSS TECH]

I disagree, CSS...the very first step in deconting anything is a visual inspection - dried on crusties will need more than a run through the washer <smile>...why not have the people in decontam give the instrument a quick once over for servicability at that time too??

Have a great day.

B
Inspection in Decontam? Wow! What kind of inspection really? The job of the person in Decontam is to make sure instruments are clean when they reach Assembly. Do you want Decontam to check if a pair of scissors is sharp or dull? The only inspection in Decontam concerns cleanliness. Broken instruments are to be taken care of by ASSEMBLY!

[Uprooted Scrub]

Actually, CSS, instrument inspection is everyone's job on the CS team at our facility. For example, while sorting through a set this morning in decontamination I found a kocker clamp that was bent. I put a repair tag on it - that saved a step for the people in assembly. After the clamp went through the washer it was placed in the repair bin.

I've asked all of the employees here to constantly be on the look out for anything that could slow down surgery (broken instruments, case cart deficiencies, etc) and correct problems as soon as possible.

By working together and getting rid of the 'that's THEIR job' attitude, our work seems to get done a lot faster and more efficiently. Also, these team building practices make our department one heck of a great place to work!!

JMHO.

Blaine:)

[jrc]

Actually, CSS, instrument inspection is everyone's job on the CS team at our facility.I could not agree more.


I've asked all of the employees here to constantly be on the look out for anything that could slow down surgery (broken instruments, case cart deficiencies, etc) and correct problems as soon as possible.By putting the responsibility on everyone at every station, you vastly improve the quality. It means a problem has to go through multiple places where it could be stopped, instead of just one. Does this make extra work for everyone? Not at all. Many problems are identified before they ever come to the person who traditionally would have identified them, so the farther down the line you go, the less time is spent on these issues.


By working together and getting rid of the 'that's THEIR job' attitude, our work seems to get done a lot faster and more efficiently. Also, these team building practices make our department one heck of a great place to work!!Couldn't say it better.

[dennalynn]

So I am curious as to the way the strung instruments are handled in assembly after coming from decotam-are they unstrung and then re-strung by assembly person so that they can be inspected and then strung in the correct order? That seems like rework to me. If they are already on a stringer how can they be properly inspected.

[CSS TECH]

Well! I don’t know how other facilities work. For all my 18 years in the CSS profession, I have been working for only one hospital!
Although you can ask everybody to be on the look out to help maintain instruments in perfect functioning condition, you really cannot make instrument inspection everyone’s job. If it were the case, what would you say to a technician sending a dull pair of scissors from Decontam? What would you say to the same technician sending some forceps not approximating properly? Would you write him up?
Instrument inspection is an Assembly job! It’s not about a “that’s THEIR job’ attitude”! Every section should have a specific job to do and it has to be done properly and always. In my facility, instrument inspection is not done in Decontam and I don’t think it will happen either. Of course, if an instrument is seen broken in Decontam, the technician working there is not going to send it through without a tag attached to it.
How does your staff inspect micro instruments in Decontam? Think about that!
And Jrc, are you and Uprooted Scrub working for the same facility? I guess so since you agree so strongly with his statement regarding his facility!

[David Freeman]

Let's clarify terms a bit before this gets hostile: I don't think anyone is suggesting that we set up a lighted magnifying glass and test each instrument for alignment and sharpness in decontam. That would not only slow the process but increase exposure to sharps injury when instruments are most hazardous. However, decontam is the best place to check instruments for obvious problems, missing instruments, extra instruments and complete disassembly. As someone said, everyone works together for the good of the surgical patient and not turn this into a "it's not my job" situation.

That being said, I am not a fan of stringing instruments in decontam. I don't think the stringers hold some instruments open adequately, especially long vascular clamps which are hard enough to make sure the tiny serrations in the jaws are free of gross dried on gunk which a washer will not adequately get rid of. On a stringer, some long vascular clamps and nine or ten inch extra long instruments just aren't held open widely enough to get clean.

[cpdguy]

Being able to talk about what the best practice is wonderful.

We all know that no two CS departmetns are alike and becasue of that we all have limits.

So many good ideas have been share on strining and inspecting instruments in the decontam area.

When it comes to strining, I truely belive that that instruments should be strung. They should be place on at least a 5 inch stringer. In my view this holds even the larger clamps open a lot beter than just pacing them in a pan on top of each other in the open position.

Now about observations in the decontam area. The last posting made great points on in the decontam area this is the first step in the process. This staff can make a lot of visual checks as they load and clean the instruments. If they notice something out of "wack", they can tag it. It is that simple. Like many of you I have worked in this area. While working I was able to pick up many concern before they got to the next point. Just from the fact I had to handle the instruments,many had to be disassembled,pick them up and move them along.

In CS we are trained to be observant. This is a great skill and it should be applied as best as possible where ever we work.

So should some type of observation of the condition of the surgical instruments take place in the dectoman area. My respons is yes, what that is is for each medical facility will depend on many factors but it should be done on some level.

Should strining be done, I feel it should if possible. Can it be done,yes; I have seen it done, yes. Has it made a difference,yes. Can each facility do it, that I am not sure of. Space,training,many factors, but I believed it should be looked at.

Hee is a direct quote concerning strining from a manager " Regarding stringing instruments. When I managed CSPD, we did implement the re-stringing of instruments prior to placing in the washer. This reduced the number of lost instruments, assembly of sets was easier and best of all, we had clean instruments!"

Because we work in a dynamic field, thier are now products that make it easier to string and prepare instrments for cleaning.

Just my two cents. Keep the dialgue going, that is how we all learn by networking and sharing ideas in a psotive manner.

Keep up the good work.

[jrc]

As David said, you do not test for sharpness in decon, but you do inspect to the point that you can. I believe we are all in agreement about the need to check over instruments, but we may disagree about what constitutes an "inspection." I think it is important (and, I believe Uprooted Scrub would agree, if I can speak for him) that it is important to maintain the mindset that we are inspecting our work to the level possible at every step of the process.

@ dennalyn: We remove the jumbled instruments from the dirty sets and string them on extra-wide stringers for decon use while we are performing our manual cleaning/inspection. Then we send them through the washers. At assembly, we remove them from the wide stringers and place them on narrower ones for sterilization.
This is no extra work for the assemblers. In fact, it makes their job easer. The decon person works a little harder, but I prefer to invest the time in cleaning, which is the most critical step in the whole work flow process. Stringing the instruments and pointing them up is the best way I have seen to present instruments for exposure to the washing process.

@ David Freeman: The long instruments do not go on the stringers. They would block the washer arms.

[CSS TECH]

David Freeman, nothing will get hostile. You want instruments to be inspected in Decontam and I don't want it. That's all! The same way some of you want instruments to be banded and I don't want it!
Cpdguy, instruments are to be observed wherever and whenever it's possible. I fully agree with that. Like I said before, when I used to work in Decontam, I never sent an instrument missing a screw, a pair of scissors with a missing blade, a retractor or anything clearly bent. However, asking for inspection of instruments in Decontamination is the funniest thing I've ever heard!

[cpdguy]

In reading your comments, I think you are inspecting instrumetns. You are doing the right thing. Is it a detailed inspection like in assembly no,not at all. But you are inspecting. That is the key point. I have seen where nothing is done. Instruments are just washed and moved along and this is not the best way to do the overall process. So I guess it is more the words we are using observation and inspection. But overall it is the action of looking at the instrument as it moves through various process. Each step in the process provide a way to observe and or inspect the items we are handling.

The most important inspection and observation takes place in the assemble (prep and pack in some places) area. Anytime we can help that process in the steps before it is important.

That I know we all agree on.

Great discussion,great points on each side.
This is how we all improve.

[CSS TECH]

In reading your comments, I think you are inspecting instrumetns.
No! I am not inspecting instruments. If I catch something wrong in Decontam, I will stop it from getting into Assembly. For example, if the wrong instrument was found on a tray, I would not put it back; if I see a rongeur with a broken spring or screw, I will not send it through, but instead I will tag it, remove it from the tray and send it by itself. You cannot call this inspection! This is not inspection!
Inspection of instruments is to be done in Assembly!

[David Freeman]

CSS Tech,

At least we agree on banded instruments. I was scrubbed on a craniotomy once and the surgeon asked for a bayonet forceps, reached into the patient's head and removed a piece of instrument tape. He then calmly instructed that all tape be removed from all his instruments.

[dennalynn]

Thank you jrc for answering my question. It makes sense to use a separate stringer. I was just not seeing how the process works. Obviously our facility does not string in decon but we have also not had a problem with instruments not being clean. It still is worth looking at the process, though. Good info-thanks everyone!

[CSS TECH]

CSS Tech,

At least we agree on banded instruments. I was scrubbed on a craniotomy once and the surgeon asked for a bayonet forceps, reached into the patient's head and removed a piece of instrument tape. He then calmly instructed that all tape be removed from all his instruments.
Yes, we do! Thanks for sharing your experience.

[SHIRLEEN VANOCKER]

where better a place to inspect instruments for cleanliness, damage, function and completeness than when initially received? The sooner an item is discovered missing, the sooner the O.R. can be notified to locate...especially those expensive items. All items should be inspected for cleanliness and cleaned properly in the decontam area. A final inspection should occur at time of set up

[CSS TECH]

where better a place to inspect instruments for cleanliness, damage, function and completeness than when initially received? The sooner an item is discovered missing, the sooner the O.R. can be notified to locate...especially those expensive items. All items should be inspected for cleanliness and cleaned properly in the decontam area. A final inspection should occur at time of set up
"All items should be inspected for cleanliness and cleaned properly in the decontam area", and I fully agree with that! However, inspection for damage and function in decontam cannot be done. It's just unreasonable to ask technicians to perform such duties when they work in decontam. Observation for missing instruments is also a good idea, and we do that at my facility.

[wperez]

When I came on board here the OR retsrung instruments. This has stopped and I would never go back to restringing instruments. It's our job to open and prepare each instrument for decontamination.

[doc7592]

My 2 cents. Navy trained OR Tech from the early 80's here. We had to string all instruments and return them in the proper trays comple If an item was broken or in need of repair it was tagged. Also we had to wipe our instrument off during the case, when the Surgeon handed it back. In my facility this is rarely done, they claim they don't have the time. I think we lose sight of what's best for the PT. If the sets are strung in the OR and placed in the proper tray it really makes everyones life a little easier. No more looking missing instruments. WEBSTER definition: a checking or testing of an individual against established standards If decontam picks it up opens it and cleans it is that not inspection? CPDGUY hurry up the publication. Everyone have a happy holiday.

[wperez]

You need to read the AAMI standards. All instruments need to be in the open position. How can you expect the decon tech in SPD to unstring and open all instruments? You have added minutes to his decon time. The OR should cooperate and place instruments back in the appropriate containers unstrung. Bottom line. The opportunity for bioburden in your trays just went up!

[CSS TECH]

All instruments need to be in the open position.
WHEN? Please, clarify!

[Harvey Johnson]

wperez,
AAMI states hinged instruments are to be an open position, working ends exposed and ratchets not engaged during the cleaning and sterilization steps, nothing else about stringers, transport or the degree they are to be opened.
The stringers I have keep the instruments in the open position as defined by AAMI.
If placed on a stringer and properly set somewhat vertical in the washer after decontaminating, stringed instruments working ends have a much better chance of benefitting from the mechanical wash pressure than instruments lying loose horizontaly in a wash basket
As far as I know AAMI has yet to weigh in on the stringer issue.

[wperez]

No stringer holds the instruments in the open position. Only the lock box is exposed. All jointed instruments refers to the joint not the lock box. So the jointed shoulb be fully open. I disagree that any instruments left strung will be effectively cleaned.

[Harvey Johnson]

You may disagree, as you have seen this is a very opinionated board, everyone's mileage may vary.....
I guess it's how you define "fully", AAMI makes no reference to degree of opening.
On your next trip out to Oregon, stop by....
Don't know about the policies and procedures and results at your house, check us out, I will demonstrate how the stringers in our department keep the instruments open and our instruments are always effectivley cleaned....

[CSS TECH]

No stringer holds the instruments in the open position. .
Are you sure of that? In my facility we use stringers that are 6" and 8" wide, and they really hold the instruments wiiiiiiiide open!:p

[pixieduster]

If placed on a stringer and properly set somewhat vertical in the washer after decontaminating, stringed instruments working ends have a much better chance of benefitting from the mechanical wash pressure than instruments lying loose horizontaly in a wash basket
As far as I know AAMI has yet to weigh in on the stringer issue.

I wish AAMI would weigh in on the stringer issue. We also place the stringer in a "somewhat vertical position" in the washer. The instruments stay open and are separated enough from each other that they get the optimum exposure. I think this is a fantastic idea and I wish I would have been trained this way years ago.

[sunshine]

Interesting......I grinned reading about how Doc was trained. A OR nurse was telling me the other day how he was trained....... the instruments are wiped down way before they get to us. He is surprised at how that practice has hit the wayside. Habit for him. I inquired with some of the new CST.....they tell me that it is still how they are trained......yet.......sign of the times I guess.

Now I know that has nothing to do with restringing,stringing, ropping of instruments. It just reminded me of how things change.

We are a (partial) restring place. Instruments that are used on pt are not restrung. They are wide open to wash. Instruments that are not used.....you know the majority of the set that sits in the room.......the stringer is ran back through the clamps, then placed with the remaining (not used) instruments. When SPD get the case, all the instrument go through washer. Lot less wear and tear on instruments and staff.

Happy Holidays!