CIS SELF-STUDY LESSON PLAN Lesson No. CIS 281 (Instrument Continuing Education - ICE) Sponsored by:

Eliminating Missing Instruments

BY MARJORIE WALL, MLOS, CRCST, CIS, CHL, CSSBB

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. Discuss the importance of maintaining accurate count sheets designed for CIS technicians, but can be of value 2. List steps to build an effective replenishment system to replace missing and nonre to any CRCST technician who works with surgical pairable surgical instruments instrumentation. 3. Review the Six Sigma technique of 5S for instrument organization 4. Discuss the importance of flow through Sterile Processing decontamination and Earn Continuing Education Credits: assembly areas to eliminate preventable missing instruments Online: Visit www.iahcsmm.org for online grading.

By mail: For written grading of individual lessons, send completed quiz and $15 to: issing instruments are and SPD runners to stop their work to go Purdue University - Online Learning a common challenge search for the missing critical instrument. Young Hall, Room 527 for Sterile Processing It is not uncommon for multiple SPD 155 S. Grant Street West Lafayette, IN 47907 departments (SPDs). This technicians to be pulled from their job lessonM will address the importance of assignments and spend 15 minutes or Subscription Series: Purdue Extended Campus minimizing the occurrence of missing longer searching for a critical instrument, offers an annual mail-in or online self-study lesson subscription for $75 (six specific lessons worth 2 instruments and developing and which creates waste, frustration and points each toward CIS recertification of 6 maintaining an organized storage and backlogged work. hours). Call 800.830.0269 for details. reorder system. Organizations spend hundreds of Scoring: Each online quiz with a passing thousands of dollars annually replacing score is worth 2 contact hours toward your CIS Objective 1: Discuss the importance in missing instruments. This stems from the recertification (6 hours) or CRCST recertification maintaining accurate count sheets surgical procedure itself being delayed or, (12 hours). Most SPDs track tray errors. These even worse, canceled because the missing More information: IAHCSMM provides online typically involve incorrect instruments, instrument is critical to the procedure. grading service for any of the Lesson Plan packaging errors, damaged instruments, When surgeons schedule procedures, varieties. Purdue University provides grading services solely for CRCST and CIS lessons. Direct etc. Most departmental leaders do not they count on the instrument trays any questions about online grading to IAHCSMM count missing instruments as a tray error being complete and ready for surgery. at 312.440.0078. Questions about written if the instrument is marked “missing” on Missing instruments are a problem SP grading are answered by Purdue University at 800.830.0269. the tray menu and labeled on the outside Instrument Specialists should strive to of the tray; however, most surgeons and prevent proactively – before they have a Surgical Services leaders would argue chance to impact the OR. that missing instruments are the highest Many may wonder what causes missing frequency tray error and are a direct instruments, and the answer will likely contributor to delays and frustration in vary depending upon who is asked. Some the surgical suite. Missing instruments in SP Instrument Specialists might claim surgical trays can halt surgical cases and the OR is largely responsible. Those in cause Operating Room (OR) circulators the SPD typically blame the OR team CIS SELF-STUDY LESSON PLAN

for throwing away instruments with the “bread and butter” instruments correct tray. For the other examples, drapes on the back table. On the other memorized like Mayo scissors and SP technicians may put a variety of hand, many OR team members might #3 knife handles, and advanced SP lengths or thicknesses of Allis forceps envision a black hole of sorts in the technicians will have a variety of in instrument trays. Additionally, SPD where all the critical instruments instruments memorized from an technicians may not be able to replace are mysteriously collecting. Healthcare assortment of service lines. For example, an instrument because they do not have administrators do not care what is they can explain the difference between enough information. Often, hospitals causing the problem; they just want Debakey, Satinsky and Cooley vascular use their own jargon on tray menus. For an end to the never-ending expenses clamps. Even the most experienced SP example, a Rochester Eastman retractor associated with replacing missing surgical technician, however, may struggle to is listed as a Kelly retractor. There is no instruments. In reality, the root cause know the differences between similar sizing information and it is the incorrect of missing instruments is complex. instruments on ear, eye and other name. The OR cannot understand why Missing instruments are typically caused microsurgery instruments. Without those in the SPD cannot get it right. SP by instruments mixed between sets, the manufacturer’s catalog information technicians must get it right, and the prioritization systems that leave critical on tray menus, new hires will struggle way to get there is by having accurate instruments behind, bad data on critical to learn the jargon and memorize the tray menus with standard nomenclature tray count sheets, and no replenishment specialized instruments in their new SP for instrument names. The following system to replace damaged instruments. roles – and even long-term employees is an example of a simple instrument For the purpose of this lesson, let’s focus may struggle or avoid trays with less- standard nomenclature that is effective: on what the SPD can control. familiar instruments. The result for instrument type, inventor or scientific both groups is the wrong instruments in name, description of direction/curvature, Counting on Count Sheets trays and instruments marked “missing.” length, and thickness (if applicable). Surgical tray menus are the critical tool When the manufacture’s catalog This structure ensures technicians can ensuring the success or failure of SPDs. information is accurate and included on quickly read tray menus to match their Count sheets are the communication tool tray count sheets, experienced and new instruments to the count sheet. It also where the OR team ensures that the SPD SP technicians can “paint by number” to ensures they have the information to team knows exactly which instrument assemble specialized surgical instrument find their instrument in other trays or belongs in which tray. Bad data on tray trays. When this happens, tray assembly from the back-up wall, and it drastically menus leads to the wrong instruments speed and accuracy is improved, reduces the risk for technicians putting in trays, no information to order missing instruments can be located, and the incorrect instrument in a surgical replacement instruments, and failure to replacement instruments can be ordered, instrument tray. follow the manufacture’s instructions if needed. As instrument count sheets are cleaned for use (IFU) for instrument processing. One of the root causes to missing and completed, the SP leader needs Instrument Specialists are set up for and/or incorrect instruments is poor to ensure the technicians understand failure if count sheets do not have the descriptions for surgical instruments on that “close enough” substitutes are critically needed information, including count sheets. Considering the following: not acceptable. When an organization the manufacturer, catalog numbers, • Forcep Allis has had poor information for years, instrument descriptions, and quantity. • Allis Clamp the surgical instrument trays likely Whether a tray menu is electronic or • Allis Clamp Med have years’ worth of poor instrument hard copy, the count sheet must be • Allis Clamp 7in substitutes or incorrect instruments. As accurate to ensure that SP technicians • Forcep Allis Tissue Straight 6 ¼” trays are processed through the SPD, can get the right instrument in the right wrong instruments will be removed, tray. All of these descriptions may be asking and correct instruments will be placed Because there are hundreds of for the same instrument; however, in trays. This may result in a short- thousands or surgical instruments, only the last instrument description term increase in missing instruments as critical pieces of the tray menu are (Forcep Allis Tissue Straight 6 ¼”) will incorrect instruments are removed and manufacturer information and catalog result in SP technicians consistently replacement instruments are unavailable. numbers. Most SP technicians have putting the correct instrument in the CIS SELF-STUDY LESSON PLAN

Objective 2: List steps to build an effective area should be organized in a way that Standardize: The fourth step in a 5S replenishment system to replace missing makes it easy to locate instruments project is to standardize. One of the most and nonrepairable surgical instruments quickly. Six Sigma has an organization effective tools for standardizing a back- Surgical instruments undergo wear technique known as 5S. This technique, up wall is use Kanban cards. Kanban is and tear during surgical procedures. which includes the following, results in a visual indicator that an action needs SPDs have preventative maintenance items being organized in a way to make to occur. Kanban cards for instrument systems set up to repair and maintain it intuitive to find and locate the critical back-up walls typically have an image of the functionality of the instruments. item when needed: the instrument, manufacturer, catalog Over time, the instruments become information, and a reorder point or par nonrepairable. When instruments Sort: The first step in a 5S project is level. The Kanban cards are placed on are damaged beyond repair, the SPD to sort. Sort instruments that are the pegs and in the bins of the back-up must have a replenishment plan. The needed from instruments that are old wall. This serves two purposes: first, replenishment plan should include a inventory and will never be used. Many SP technicians have labels with images system for having instruments on hand third-party instrument vendors and for each instrument. This keeps the for high-use instruments and a separate some manufacturers will purchase old back-up wall organized, and when new system for purchasing replacement instrument or give trade-in credit toward instruments come in, they can be quickly specialty instrumentation. new purchases. Remove any broken put in the right location. The second Departments can build a back-up damaged instruments and send them purpose leads to sustainability. supply of instruments, either through for repair if they can still be used. For purchasing high-use instruments or any nonrepairable instruments or dead Sustain: The final S in a 5S project is to engaging in a consignment system with inventory that is unsellable, consider sustain. A system needs to be developed their contracted instrument vendor. Some recycling. The important thing is to to ensure that the organization and instrument repair companies will include only keep instruments in the backup replenishment of the back-up wall stays replacing high-use instruments as part inventory that will be used. in place. Kanban cards can be placed at of their repair service. The instruments the reorder points for the instrument in any of these systems must be the right Set in order: The next step in a 5S project back-up wall. The cards have the critical mix of instruments and organized in a is to set in order. Organize instruments information that the requisitioner will way to ensure SP technicians can find to promote workflow and place high-use use to order replacement instruments. the instrument they need as quickly instruments in easy-to-reach locations; At least annually (if not more often), as possible. Instrument use should be low-use items should be located farther the organization should reanalyze analyzed to identify the most frequently- away. Instruments primarily used in the the instrument utilization data and used instruments in the department. For low-temperature sterilization area should nonrepairable instrument trends to departments with surgical instrument be stored there. If the instruments are adjust the back-up wall instrument mix, tracking systems, the information can be primarily used to replace nonrepairable as appropriate. exported by the system. It is important instruments, perhaps they should be Having a well-functioning back-up to evaluate the frequency of use for each located near where trays are checked back wall is critical for high-replacement type of instrument across all trays. The in from the onsite repair team. Organize instruments that are at end of live or department should focus on creating par the space so it is easy and intuitive to use. nonrepairable; however, facilities can levels for back-up instruments matching have over 20,000 types of instruments highly-used instruments. Instruments Shine: The third S in a 5S project is to in their instrument trays. Not all with a greater risk/tendency for damage shine. The area should be cleaned, so it instruments can be managed through or wear (e.g., osteotomes) should also be is neat and tidy. Dust the back-up wall a back-up wall. For those specialty included. peg board or bins. Remove and replace instruments that are high value, low any old or worn labeling. Remember, utilization, or super specialized, the Objective 3: Review the Six Sigma instruments stored in the back-up area organization will need an alternative technique of 5S for instrument organization will be placed in trays for surgery; they system for managing missing and Once the selection of instruments is should be stored in a clean, sanitary nonrepairable instruments. The completed, the back-up instrument environment. specialized instrument should be CIS SELF-STUDY LESSON PLAN

communicated to the OR. Some day. One-of-a-kind trays can be fast instrument replacement, many of the instruments are so specialized that the tracked through the decontamination occurrences of missing instruments can associated surgical procedures cannot area. If there is not a consistent flow be reduced. be performed without the critical process, SP technicians can choose instrument. If the instrument is not which instruments to send through in available, the organization may need to which order. All these behaviors lead to borrow or get loaned instruments, or the same issue: instrument trays from worst case, reschedule surgeries. Note: the same case cart being sent through This should be vetted as soon as possible to the washers at different times. When reduce any patient care impact that could this happens, instrument trays then occur. After the instrument is confirmed arrive in the assembly area, Instrument lost or nonrepairable and communicated Specialists attempt to assemble the to the OR team, the SP team then needs trays and, unfortunately, the sets are to order the instrument. Ideally, the missing instruments that are still in tray information can be included on other trays from the original case cart the purchase order or documented to in decontamination. The instruments print on the delivery receipt when the are marked as missing and the trays instrument arrives. This will simplify the are sterilized. The next morning, when process for getting the instrument on the the tray is used in surgery, it is missing right tray as quickly as possible. critical instruments. The instruments are then found in the SPD and the OR team Objective 4: Discuss the importance cannot understand why the SPD “cannot of flow through Sterile Processing get it right.” decontamination and assembly areas to Instrument Specialists should focus eliminate preventable missing instruments on what they can control and avoid While the OR team can certainly the blame game. The SPD can control contribute to missing instruments, the flow of instruments through it is not always in the way most SP decontamination and assembly. Trays technicians believe. Many missing from the same case cart should be kept instruments mysteriously reappear together through decontamination and the following day in the SPD. Many SP assembly. This will reduce search time professionals may have experienced in the instrument assembly area and the OR coming to the SPD and finding reduce the occurrence of preventable a critical instrument in a random bin. missing instruments. Tags validated for Most SPDs experience this daily and in decontamination processes can be used large “mega departments,” it can occur to keep these trays together through the several times a day. This type of missing processes. Employee engagement and instrument root cause is typically the buy-in will ensure success for improving OR team mixing surgical instruments the flow of instruments in an SPD. in multiple trays. When instruments are mixed on the sterile field and not re- Conclusion sorted prior to SPD receipt, this increases While missing instruments will remain the risk for missing instruments. In an issue in the SPD, the occurrence the SPD, there typically is a list of can be decreased. By focusing on the priority trays for the day; these trays processes that can be controlled by are pushed through decontamination the SP technicians and developing an as soon as they arrive because they organized and well-maintained system are needed for surgeries later in the of instrument processing and missing CIS Self-Study Lesson Plan Quiz - Eliminating Missing Instruments Lesson No. CIS 281 (Instrument Continuing Education - ICE) • Lesson expires September 2023 CIS SELF-STUDY LESSON PLAN

1. Which of the following can occur when 5. Standard nomenclature on surgical tray 10. Ensuring trays from the same case cart are instruments are marked “missing” for count sheets ensures that: kept together through the decontamination surgical trays? a. Sterile Processing technicians can and assembly processes can: a. The Operating Room team may have to quickly read tray menus to match their a. Extend processing times search for a sterile replacement for the instruments to the count sheet b. Reduce search times and minimize missing instrument b. No instruments will go missing occurrences of missing instruments b. The Sterile Processing team may be c. Sterile Processing professionals will not c. Cause bottlenecks in the pulled from job assignments to search for be blamed if instruments go missing decontamination process critical missing instrument d. A back-up instrument is available in the d. All the above c. The surgical case may become delayed Sterile Processing department, if needed or canceled 11. The first step in the 5S system is: d. All the above 6. Back-up wall instruments must be: a. Shine a. The right mix of instruments and b. Set in order 2. Which of the following can result in missing organized in a way to ensure technicians c. Sort instruments? can find the instrument they need as d. Standardize a. Instruments that are mixed between trays quickly as possible. on the surgical field b. Inventoried weekly 12. Placing the high-use instruments in b. Priority trays being expedited through c. Maintained in a closed cabinet the most accessible location in the backup decontamination without the trays from d. Used only if the tray is needed the same instrument storage location is an example of the same case day which of the 5S project steps? c. Poor descriptions on instrument tray a. Standardize count sheets 7. Which of the following instruments b. Sustain d. All the above should not be included in a Sterile c. Setting in order Processing department’s back-up d. Sort 3. Bad data on tray menus can lead instrument to incorrect instruments in trays, no wall inventory? 13. Instrument utilization data should be information to order replacement a. High-utilization instruments analyzed at least: instruments, and failure to follow the b. Instruments with greater tendency for a. Monthly manufacturer’s instructions for wear, like osteotomes b. Yearly use for instrument processing. c. Rarely-used instruments that may be c. Weekly a. True needed just in case d. Semiannually b. False d. Instruments that historically have had a high damage or replacement rate 14. One cause of missing instruments is: 4. Which of the following does not need to be a. Point-of-use preparation included on surgical instrument tray count 8. Which of the following is not part of a Six b. Instruments placed in sets in the sheets? Sigma 5S project? Operating Room a. Name of the manufacturer a. Sort c. Sets mixed on the sterile field b. Catalog numbers b. Save d. The use of duplicate count sheets c. Accurate descriptions c. Set in order d. Purchase quantity d. Standardize 15. To reduce the occurrence of missing instruments, instrument technicians should: 9. Kanban cards can help standardize a. Control the flow of instruments through instrument back-up walls and provide a the decontamination area replenishment system for routine b. Expedite only one tray from a case replacement of high-use instruments. c. Only sterilize complete sets a. True d. Use only electronic copies of count b. False sheets

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