CIS SELF-STUDY LESSON PLAN Lesson No. CIS 278 (Instrument Continuing - ICE) Sponsored by:

Operating Room Set up and Breakdown: How Instrumentation Errors Impact Surgical Cases

BY PATTI KONCUR, CRCST, CHMMC, ACE – IAHCSMM CLINICAL EDUCATOR

Certified Instrument Specialist (CIS) lessons provide members with ongoing education in the complex and ever-changing area of surgical LEARNING OBJECTIVES instrument care and handling. These lessons are 1. Describe the basic routines for Operating Room case set up designed for CIS technicians, but can be of value 2. Discuss the impact an incomplete or soiled case cart or surgical tray has on case to any CRCST technician who works with surgical set up instrumentation. 3. Review surgical case breakdown processes and how time restrictions affect these processes Earn Continuing Education Credits:

Online: Visit www.iahcsmm.org for online grading.

By mail: For written grading of individual lessons, case-ready Operating Room Ensuring patient safety in the OR send completed quiz and $15 to: (OR) is one that is properly begins before the patient enters the Purdue University - Online Learning cleaned and staged with surgical suite and includes attention to Young Hall, Room 527 155 S. Grant Street case-specific instrumentation. all applicable types of preventable errors, West Lafayette, IN 47907 A case-ready OR helps ensure OR including instrumentation errors. Today’s providers have everything they need to Sterile Processing department (SPD) Subscription Series: Purdue Extended Campus offers an annual mail-in or online self-study lesson deliver exceptional care and positively deals with more diverse instrumentation subscription for $75 (six specific lessons worth 2 influences the surgical team, patient and more advanced processing points each toward CIS recertification of 6 and surgical outcome. equipment than in the past. , the hours). Call 800.830.0269 for details. The surgical team typically comprises primary users of these instruments, are Scoring: Each online quiz with a passing the , OR nurse (RN Circulator), increasingly aware of the challenges that score is worth 2 contact hours toward your CIS anesthesiologist, , often exist with instrument handling, recertification (6 hours) or CRCST recertification (12 hours). assistant, surgical technologist and the role the surgical staff play in the and peri- technologist. complete reprocessing cycle; however, More information: IAHCSMM provides online Surgical team members typically follow there is often a gap between what SP grading service for any of the Lesson Plan varieties. Purdue University provides grading routines for OR set up and breakdown. professionals know about the factors and services solely for CRCST and CIS lessons. Direct They also ensure that the OR is challenges associated with instrument any questions about online grading to IAHCSMM thoroughly cleaned to establish the sterile turnaround and what the surgical team at 312.440.0078. Questions about written grading are answered by Purdue University at field, and staged with all instruments members require or demand. Teamwork 800.830.0269. and equipment specific to the upcoming and effective, ongoing communication . All surgical team members between surgical team members and SP adhere to the principles of asepsis and professionals are essential. implement those principles for every This lesson addresses correct processes surgical procedure to reduce the risk for ensuring that an OR is case-ready of the patient acquiring a surgical and the ways instrumentation errors that site infection (SSI). occur before set up, during set up and CIS SELF-STUDY LESSON PLAN

during surgery can impact the surgical robotic console and electrosurgical affect the case load for the remainder case. This lesson also reviews how time unit. The card also lists instructions on of the day. In addition, surgeons have a restrictions can affect the process of how to position and drape the patient, schedule with specific times for surgery, OR breakdown. and any specific details pertaining to the usually followed by office hours. When procedure and surgeon performing it. OR expectations are not met, a patient’s Objective 1: Describe the basic routines for • The CST damp dusts the room and care can be delayed or adversely affected, Operating Room case set up verifies that all furniture (e.g., IV stands, which affects not only the surgical team OR set-up routines may vary from sitting stools, anesthesia provider’s but also the patient and their loved ones. facility to facility; however, the principles cart) and equipment (e.g., electrosurgical SP managers strive to provide optimal of asepsis remain the same. What follows unit and suction system) are in the OR service line inventories for instruments, are standard OR set-up routines: prior to opening the sterile items. Each supplies and equipment. Efficient item is checked for proper function. supervision of these three inventories • All surgical procedures require an • Surgical team members adhere to supports the surgeon and the service, assortment of general instrumentation sterile technique when opening whether it is , orthopedics, and procedure-specific instrumentation. sterile instrument sets, packages , , cardiovascular, The day before surgery, case cart and peel packs. If the instruments were gynecology or another specialty. SP assembly begins with a surgeon and a not wrapped and sterilized during the managers must also manage instrument procedure-specific pick sheet. The pick preceding shift, the OR nurse will sets and surgical equipment to meet sheet details the instruments, trays and ensure that instrument sets are placed the time constraints of scheduling supplies needed for the case (the pick in the autoclave. and case turnover. sheet does not contain the exact same • When the surgical team begins to open Instrument availability problems can information listed on the preference sterile items, traffic in and out of the begin in the SPD when many used case card). The day of surgery, the case cart OR is monitored and controlled. OR carts are permitted to sit for long periods with sealed sterile instrument trays is traffic flow and the number of door of time; this practice allows blood and sent to the OR. openings during a procedure have bioburden to dry and remain on the • The OR nurse manages all necessary been linked to higher airborne devices, which makes cleaning and care inside the surgical suite. The bacterial counts and the potential for decontamination more difficult. Another OR nurse, often assisted by a Certified increased postoperative infection. delay can occur if instruments are not Surgical Technologist (CST) and scrub • Sterile supplies are placed on the tables placed back in the proper location. technician, study the OR schedule in or stands, opened and set up as close to Incomplete case carts that are not ready detail prior to the surgery to carry out the time of surgery as possible (and for for the surgical procedure can occur duties effectively. The OR nurse knows one surgery only). The packs and when SP technicians cannot locate the the instruments, equipment and sets are opened in the order in which correct instrument. supplies needed in order to provide the scrub will need them. Packages are When proper protocols are not appropriate items without loss of time. positioned so the flaps are on top. followed, spotting, staining or rusting • The CST assists the nursing staff in can also occur on instruments; if not preparing the OR environment for the Objective 2: Discuss the impact an addressed prior to the device(s) being surgical procedure. incomplete or soiled case cart or placed in instrument trays for surgery, • The OR nurse cross checks the surgical tray has on case set up this can jeopardize patient safety and surgeon’s preference card against the To effectively perform surgical increase infection risks. instruments, supplies and equipment procedures, surgeons require Each surgical case is attached to a that have been “pulled” for the procedure instrumentation that is clean, procedure, which generates a preference to confirm everything needed to functional, complete and sterile. When card that includes the instrumentation prepare the sterile field for the surgical instrumentation sets are incomplete or requirements for the case. The procedure is present. The preference not acceptable for use, patient care is database for each piece of equipment cards are physician and procedure delayed, and a negative domino effect and instrumentation supporting the specific and list all items needed for the can result. Delays in the OR are costly preference card has an equipment case, including items such as the and cause operational problems that can conflict alert capability. When the CIS SELF-STUDY LESSON PLAN

system reaches its maximum instrument turnover time. As a routine, the OR nurse stand with a sterile water-soaked requirement, the scheduling system alerts or CST maintains sterility of the Mayo sponge to remove gross soil and the scheduler of a conflict. If schedulers stand and keeps a minimum number of placing the instruments inside the pass the conflict messaging without sterile instruments on the stand in the appropriate instrument container. making note, they can cause overbooking event the surgeon may need to perform To prevent damage, heavy instruments of instrumentation. an additional procedure before the should be placed on the bottom In addition, surgeons often add patient is transported out of the OR. of the container and lighter/smaller elective cases without any awareness Remaining instruments on the Mayo instruments should be placed on top; that instruments are in use or stand may include: a knife blade, four • Placing sharp instruments (Gelpi unavailable. As a rule, add-on cases Crile or Kelly hemostats, curved Mayo retractors, reamers, trocars) in a override scheduled procedures and use and Metzenbaum scissors, two Army- separate basin; the available instrumentation. Timely Navy or Richardson retractors and two • Placing delicate instruments back into communication among schedulers, the needle holders. their container to prevent damage; OR resource coordinator, instrument During breakdown of the OR, the • Flushing lumened instruments with technicians, and SP professionals is OR nurse or CST must follow standard sterile water; critical for keeping the schedule running precautions to prevent contact with • Ensuring ratcheted instruments smoothly and ensuring that sufficient blood and body fluids. They must remain open and then placing them on instrumentation is available for surgical also apply the principles of economy a stringer; cases. Communication and teamwork are of motion by establishing a logical, • Disassembling instruments with essential to ensure a smooth surgical case. sequential routine for breaking down the multiple parts in accordance with the Missing instruments cause surgical sterile field. manufacturers’ written IFU; delays and, many times, result in the need Personal protective equipment (PPE) • Applying an approved enzyme/ to open additional sterile sets to complete should be worn when breaking down the surfactant to instruments; the original set. A missing instrument sterile field to protect against exposure • Placing instruments in the appropriate can significantly disrupt OR efficiency. to bloodborne pathogens. The first instrument container inside a case cart Soiled instruments cause delays in scrub, the individual who knows the to prevent cross contamination during surgery while a clean set is obtained. location of sharps and contaminated transport to the SP decontamination If a soiled instrument is placed on the items, is the one who is responsible room; sterile field, the entire case may have to for breaking down the sterile field and • Ensuring instruments that were not be broken down, with new instruments applying the principles of point-of-use used during procedure are placed and drapes obtained and the room being (POU) treatment (the beginning of the in their respective instrument tray to reset. This is costly for the facility due to instrument cleaning process). prevent instrument damage; the extra supplies and time required. Sharps should be handled and • Separating disposable items by waste discarded according to facility policy categories and disposing of them in Objective 3: Review surgical case and Occupational Safety and Health accordance with local, state and federal breakdown processes and how time Administration standards that address regulations. All disposable items restrictions affect these processes sharps safety. should be placed in the impervious Standardized OR turnover procedures Standard routines for breaking down red waste bag identified by the are crucial for a timely preparation of the sterile field include the following: biohazard symbol; the surgical suite for the next scheduled • Ensuring suction canisters and tubing procedure. The breakdown process • Adhering to the facility’s process for are discarded according to facility involves many individuals, in addition to identifying instruments that need policy and local regulations; the OR nurse and CST, and can include repair and removing them from service; • Removing PPE and discarding it in a anesthesia technicians, equipment • Referring to the instrument biohazardous waste bag; technicians, biotechnicians and OR manufacturer’s instructions for use • Removing biohazardous waste from cleaning staff. (IFU) regarding recommended the OR and placing it in the designated A major focus of surgery departments cleaning solutions for instruments; area for removal by Environmental is to improve the efficiency of OR • Wiping instruments from the Mayo Services personnel; CIS SELF-STUDY LESSON PLAN

• Performing a medical handwash by the • Retrieving all case-appropriate successfully achieve a case-ready OR CST or scrub technician; and equipment for the next case. where workflow sequence, timing and • Ensuring that contaminated items are dependencies align. contained during transport from the OR cleaning staff duties include: OR to SP decontamination room. RESOURCES • Collecting and removing all trash, Association of Surgical Technologists. Guidelines Anesthesia technician duties include: biohazardous waste, and linens; for Best Practices for Breaking Down the Sterile • Checking the sharps container (close, Field. June 1, 2018. • Performing “end case” on the monitor; seal and replace at 2/3 full); • Cleaning the anesthesia machine; • Wiping down the overhead light with a Association of Surgical Technologists. Guidelines • Wiping down all anesthesia-related -approved disinfectant (HAD); for Best Practices for Establishing the Sterile equipment; • Washing horizontal surfaces of Field in the Operating Room. October 20, 2018. • Replacing the suction, circuits, furniture and equipment with a HAD; electrocardiogram (ECG/EKG) patches • Removing the surgical waste British Columbia Institute of Technology. CSPS and pulse oximeter; management system and initiating the Surgical Team Member Role. Council on Surgical • Filling vaporizers and hot lines, as needed; cleaning procedure; & Perioperative Safety. July 10, 2019. • Checking and replacing carbon dioxide • Inspecting walls and cleaning debris, (CO2), as needed; as necessary; Occupational Safety and Health Administration. • Removing excess moisture from the • Cleaning the floor of debris using a 29CR 1910.1030 Bloodborne pathogens. water trap; wet microfiber mop with an approved Surgical Asepsis and the Principles of Sterile • Cleaning and removing all extra cleaning/disinfecting chemical, and Technique. 2010. equipment; placing the “wet floor” sign; • Verifying blood pressure cuffs are • Restocking gloves, disinfecting wipes International Association of Healthcare Central available in all sizes; and the hand sanitizer dispenser; and Service Materiel Management. Central Service • Stocking the cart and removing all • Visually inspecting the room to ensure Technical Manual. 8th Ed. 2016. extra supplies; cleanliness and spot cleaning, as required. • Confirming an emergency back-up Association for the Advancement of Medical oxygen tank and Ambu bag are present The preoperative case management Instrumentation. ANSI/AAMI ST79: 2017, at the time of turnover; and routine should be repeated in Comprehensive guide to steam sterilization and • Ensuring the anesthesia cart is locked. preparation for the next procedure (this sterility assurance in health care facilities. includes repositioning the OR furniture). Equipment technician duties include: Centers for Disease Control and Prevention. Stop Conclusion Sticks Campaign. 2020. • Checking with the OR nurse and Instrument availability and reliability returning blood products and/or are essential for a safe, well-run, cost- coolers to the blood bank; effective OR environment. Effective • Inspecting the OR table for cleanliness; teamwork among the surgical team and • Checking for correct bed and room SP professionals can identify deficiencies setup, according to the preference in the system and decrease the number card; and of minor problems, which can lead to a • Setting up as supine if there is no case smoother, safer and shorter surgery. to follow for the next day. Before, during and after a surgical case, every individual involved, every piece Biotechnician duties include: of equipment and every decision must result in a seamless, synergistic • Cleaning all equipment not needed for outcome. Today’s complex systems the next case before removing it from and instrumentation in the surgical the OR; and field demand strong teamwork to CIS Self-Study Lesson Plan Quiz - Operating Room Set up and Breakdown: How Instrumentation Errors Impact Surgical Cases Lesson No. CIS 278 (Instrument Continuing Education - ICE) • Lesson expires March 2023

1. Ensuring patient safety in the Operating 6. Case breakdown typically involves: 11. Lumened devices should be flushed with Room begins: a. The Operating Room nurse and the saline and disassembled for transport to a. When the patient enters the surgical surgical technologist the decontamination area. suite b. The surgeon and a biotechnician a. True b. During patient positioning c. The Operating Room nurse and b. False c. When the patient is being transferred the surgeon from the stretcher to the surgical table d. The surgical technologist and the 12. Teamwork between the surgical team and d. Before the patient enters the surgeon Sterile Processing professionals can: Operating Room a. Decrease the number of problems 7. Which individual is responsible for experienced in the Sterile Processing 2. The case pick sheet contains the exact point-of-use treatment of instruments department and the Operating Room same information listed on the after a surgical case? b. Identify deficiencies in the system preference card. a. The Operating Room nurse c. Ensure a safer surgical procedure a. True b. The first scrub technician d. All the above b. False c. The equipment technician d. All the above 13. Surgical team members adhere to: 3. During case set up: a. Surgical set-up procedures from the a. The Operating Room nurse manages 8. During case breakdown, unused Association for the Advancement of all care instruments should be separated from Medical Instrumentation b. The surgical technologist prepares the the used instruments and sent to the b. Occupational Safety and Health patient for the case decontamination area in a separate Administration standards for surgical c. The instruments are checked against case cart. case management the preference card a. True c. Requests from the surgeon d. All the above b. False d. The principles of asepsis

4. Incomplete sets in the Operating Room 9. Anesthesia technicians are responsible for: 14. When are surgical supplies opened and can cause case delays and: a. Assisting the surgical technologist in set up for a procedure? a. Increase costs for the facility instrument point-of-use-treatment a. At the beginning of each shift b. Affect the Operating Room case load b. Discarding the suction canisters b. While the patient is in the Operating for the remainder of the day c. Replacing the carbon dioxide, as Room c. Disrupt the surgeon’s office schedule needed c. As close to the time of surgery as d. All the above d. All the above possible d. Once the room is available 5. When a soiled instrument is placed on 10. The Operating Room cleaning staff are the sterile field during case set up: responsible for: 15. Instrument availability can be affected by: a. The case must be cancelled and a. Checking and replacing sharps a. Add-on cases rescheduled containers, as needed b. Delayed decontamination processes b. Administration must be notified b. Cleaning walls, as needed c. Missing or soiled instruments c. Surgical costs are increased, and the c. Restocking the hand sanitizer d. All the above case may be delayed dispenser, as needed d. All the above d. All the above

Request for paper/pencil scoring (please print or type information below) ______m I have enclosed the scoring fee of $15. (please make checks payable to Name Purdue University. We regret that no refunds can be given) ______m Check here if you have a change of address Mailing Address (be sure to include apartment numbers or post office boxes) m Check here if you wish to have your results emailed to you ______Detach quiz, fold, and return to: City State/Province Zip Code/Postal Code Purdue University - Online Learning ______Ernest C. Young Hall, Room 527 ( )Daytime telephone IAHCSMM Membership Number 155 S. Grant Street West Lafayette, IN 47907 ______800.830.0269 Email Address If your name has changed in the last 12 months, please provide your former name Purdue University is an equal access/equal opportunity institution