• ••• •Lesson Jtuthor

Lynda Balcerek, f,RCSTOR Support Assistant

Community Memorial H spitalMenomonee Fa Is, WI

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ACADEMY24

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A typical health care facility has thousands of different surgical instruments, and many of them lookvery similar. Others are identical, but they are designated for use in specific procedures. In spite ofthese challenges, Certified Instrument Specialist (CIS) technicians must always ensure that the correctinstruments are placed in the proper trays.

Basic knowledge about instrument identification is a must for all processing personnel in Central SterileSupply Departments (CSSDs) Initial training programs for new employees and ongoing inservice sessionsfor all staff members are among the methods used to provide this information.

In addition, three basic types of surgical instrument marking systems are in common use. Each can helpprovide a fast easy and accurate way for busy CIS technicians to make consistently accurate instrumentidentification decisions. The careful selection and use of one or more of these marking systems shouldbe an important priority for today's CSSD personnel

Information to assist with these responsibilities IS the topic of this lesson.

Benefits of Instrument Marking

There are several important reasonswhy instruments should be marked foridentification, and they include:

• A marking system can identifyinstruments from different departmentswithin a facility or from differentlocations in a regional organization.In some hospitals, each departmentis responsible for purchasing its owninstruments, and then the need for aninstrument marking system to identifyinstruments on a per-department basisbecomes even more important

• CSSD personnel will better knowwhich instruments should be includedin specialty trays when identificationinformation is included within thecoded markings on the instruments .

• Marking systems make it easier fornew employees to recognize surgicalinstruments.

• Marking makes it easy to determinefacility and surgeon ownership ofspecific instruments. This is much moredifficult to do when instruments arenot marked.

• Marked loaner instruments are veryeasy to spot, track and manage whilethey are at the facility.

• Misplaced instruments are easier tofind when they have been marked.

Marking InformationThe information to be included in aninstrument marking system should beagreed upon by personnel from eachof the departments who will handle theinstruments. For example, if a taping systemwill be used, staff members from eachdepartment should select the single color oftape that should be used for all instrumentsfrom their department Tape is available inmany colors, and some manufacturers offerdesigns, such as stars, to provide an evengreater variety of marking options.

Personnel from each facility must Lerminethe information to be identified in .n etchingsystem. Typically, the owning de lartment'sinitials and the set or instrume ~ numbershould be included. For example, j"OB DEL"on a Kelly clamp means that i· strumentis part of a delivery set that lklongs tothe obstetrics department. Mo ~ specificinformation about an instrument' !purchaseor repair dates may also be add d to theetching system in use. ITaping Systems I

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There are several basic types of ill trumentmarking systems available, nd CIStechnicians should understand th basics ofeach type. One common method ses tape.

Several simple but important p loceduresshould be used to tape instrum~nts. TheCIS technician should clean his or ~:erhandsand fingers with rubbing alcohol t~removeoils, grease and any possible di, . Then,the instrument should be cleane lper themanufacturer's instructions for u~e. Thesite of the instrument where the ape willbe placed should be cleaned wit alcoholto remove any lubricant or moist re thatmight be on it. Allow the instrume It to drythoroughly.

Cut the marking tape on an angle 0 allowits edge to lay flat (see Figure 1). Th n wrapthe tape around the instrument one toone-and-one-half times. Figure 2 sows aninstrument that has been wrapped ith anexcessive amount of tape.

Marking tape should be applied on theshank of the instrument. Forceps shouldbe taped on the proximal end. Re ractorsshould be taped on the handle. A1PlY thetape with a firm, pulling tension .•nd donot apply excessive tape. After the!tape isapplied, autoclave the instrument '0 helpthe tape bond to the instrument. N<jjte:It istypically best to use only one piece IDf tapeon each instrument because less ti I e willthen be needed to replace the tap: whennecessary. ITaping is a quick and simple way to Iark aninstrument The variety of colors a ilable

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allow CSSDtechnicians to easily tell where aninstrument goes. For example, instrumentstaped in red belong in the cardiology sets.In contrast, instruments taped in blue mightbe for the obstetrics department.

Instrument taping is not a permanentmarking solution. Over time, the heat fromthe sterilizer will make the tape brittle, andthen the instrument will require re-taping.The marking tape should be carefullyinspected each time the instrument isprocessed to confirm that it is lying flatagainst the instrument's surface. If the tapeis cracking, peeling or chipping, it shouldbe replaced. The reason: these areas cantrap soil and microorganisms and, by doingso, hinder the cleaning and sterilizationprocesses required for instrument reuse.

Also, chips of tape can break off during aprocedure and remain at the surgical site.

When the tape starts curling, it will need tobe completely removed. A product that isavailable commercially may be purchased tohelp remove the tape being replaced. The

Figure 1

residue on the instrument will then needto be wiped off with rubbing alcohol. Theinstrument can then be cleaned and re-taped following the procedures describedabove.

Questions about the sterility on theinstrument's surface beneath the tape havebeen raised in IAHCSMM discussion forumsand elsewhere. A study conducted severalyears ago and reported in the Journalof Healthcare Material Management1

(indicated that, if the tape is appliedcorrectly, the instrument is sterile underthe tape. The summary reads, in part:

"Spores of B. stearothermophilus wereplaced between the marking tape anda metal instrument that was exposed toheat (275°F; 135°C) for three minutes ina gravity displacement sterilizer. Spore killwas achieved, so it appears that sterility ispossible on instrument surfaces exposed tothe conditions of the study."

Dipping SystemsAn instrument handle may be marked witha heat-fused nylon in a process usuallyreferred to as "dipping." This is typicallydone in a repair facility and involves the useof a powder coating that is fused to theinstrument with heat, thereby leaving a layerof nylon remaining on the instrument

The ability to match colors on the instrumentsmakes set assembly easy; however, thecoating is thick, and this can make theinstrument difficult for the surgeon to grasp.Small, delicate instruments and double-ended instruments are very challengingto coat Nylon coating can last for years,but once the coating begins to chip, thenylon must be removed, and re-coatingis necessary. Failure to do so may lead tocoating particles that can be left at thesurgical site.

Careful instrument management is neededto ensure that the entire set can remainout of service for the time required for thedipping service to be performed at therepair facility; therefore, it is best to do themarking before the set is put int circulation.

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Etching Systems

Etching systems use different ~rocesses toput information onto the instr ment. Thereare three types of etching syste s: dot peen,electrolytic chemical, and laser.

Dot peen marking systems usefa pneumatic(air under compression) mar ing needleto engrave text, bar codes 0 logos ontoinstruments. This method d mages thesurface of the instrument and creates a placefor microorganisms to grow. T~erefore, thistype of etching system should net be used tomark surgical instruments.

Electrolytic chemical marking sys!ems transferan image from a stencil onto a instrumentusing electrolytes (electrically-c arged ions)and electricity. They cannot be~sed to markplastic or other non-metal inst uments, butsmall and delicate metal instru ents may bemarked with this system.

A stencil is required when th electrolyticchemical marking system is sed. Thoserequired for short-term use c n be madeat the facility by CSSD person el; however,stencils that will be used over longer timeperiods will need to be cre ted by thesystem's manufacturer. As with 0 her systems,the information to be used in he markingsystem and that will need to be entered intothe stencil should be agreed- pon by allinstrument users.

Electrolytic chemical marking ystems arelightweight and easy-to-use. Ex ept for thecreation of long-term use stencil, the systemallows for the instrument rnarkirn to be donewithin the facility rather than a an externalrepair service. One possible challenge:additional labor hours may be ne ded for theinitial roll-out of this system.

The markings are semi-perm~nent, andthey can be buffed off during the time ofinstrument repair. Also, the ima e itself mayrub off over time, and then it Wilillneed to bere-applied.

Laser etching systems make us of a twodimensional matrix" dot" that is permanentlyapplied to the instrument. This dtt is read bya computer much like a Unive sal ProductCode (UPC) is read at a retail s ore when a

product being purchased is skimmed acrossa scanner by the sales clerk or purchaserduring the self-service check-out. Note:Many instrument manufacturers now do laseretching as part of the manufacturing processat their plants.

Laser etching systems are typically integratedwith fully automated tracking systems. Thisenables marked instruments to be easilytracked through all distribution, processingand storage steps.

The laser etching process is permanent, andit can also be costly when off-site set-upcharges must be incurred. With some systems,CSSD technicians can be taught how to applymarkings within the facility by the vendor.

Metal instruments are laser etched onthe handle or the box lock. Some smalland delicate instruments can be marked;however, instruments with plastic handlescannot be marked this way. Manufacturersof software for automated tracking systemstypically provide an alternative method forinstruments that can't be etched, so they canbe included in the tracking system.

The initial rollout of a laser etching trackingsystem can take several weeks. The processwill involve many labor hours because, forexample, all individual instruments and setswill need to be opened for etching; therefore,proper planning and coordination withoperating room personnel becomes veryimportant.

In Conclusion

Instrument marking makes the work of CIStechnicians much easier. Careful planning isrequired to help make the marking processsimple and hassle-free; however, thesesystems are cost-effective because they helpto ensure that surgeons have the correctinstruments at the correct times. They arealso very useful in managing the healthcarefacility's very expensive and very extensiveinstrument inventory.

AcknowledgementsThe author wishes to thank Ms. AllisonWilson from Spectrum Surgical; Mr. SaschaOstanek from Ostling; and Mr. Jim Creasonfrom Censis Technologies, Inc.

End Note:(1) Flash sterilization and instrument tape:an experimental study. Journal of HealthcareMateriel Management, October, 1993

References:(1) International Association of HealthcareCentral Service Materiel Management.Instrumentation Resource Course:Identification, Handling and Processing ofSurgical Instruments. Chicago, IL. 2005.Chapter 9.

(2) International Association of HealthcareCentral Service Materiel Management.Central Service Technical Manual. Chicago, IL.2007. Chapter 11.

Technical EditorCarla McDermott, RN, ACE, CRCSTClinical Nurse IIISouth Florida Baptist HospitalPlant City, FL

Series Writer/EditorJack D. Ninemeier, Ph.D.Michigan State UniversityEastLansing, MI

IAHCSMM acknowledges the assistanceofthe following two CSSDprofessionalswhoreviewed this quiz:

Lisa Huber, BA, CRCST, ACE, FCSSterile Processing ManagerAnderson Hospital Maryville, IL

Paula Vandiver CRCST, CISCS Technician, Orthopedic Specialist,Anderson Hospital, Maryville, IL

1. One advantage to marking in truments is 7. Tape on an instrument should be 12. Which etching system is typicallythat it allows a CIS technician to determine inspected: integrated with a fully automated trackingthe department to which an i strument a. Once a week system?belongs. b. Once a month a. Dot peena. True c. After every use b. Electrolytic chemicalb. False d. After every other use c. Laser

d. All of the above

2. Specialty trays and loaner inst uments are 8. An instrument can be marked with amore difficult to sort when a arking dipping system by CSSD personnel within 13. Instruments made of any material can besystem is used than when no nstrument their department. laser etched.marking system is in place. a. True a. Truea. True b. False b. Falseb. False

9. Which etching system should not be used 14. Instruments that are laser etched can be3. Only CSSD personnel should etermine on surgical instruments? tracked through which of the following

what marking information sh uld be a. Dot peen steps.placed on an instrument. b. Electrolytic chemical a. Distributiona. True c. Laser b. Processingb. False d. All of the above systems can be used c. Storage

d. A and B abovee. All the above

4. Rubbing alcohol should be us d to clean a 10. Which etching system requires a stencil?CIS technician'S fingertips bef re he or she a. Dot peentapes an instrument. b. Laser 15. The initial rollout of a laser etchinga. True c Electrolytic chemical tracking system can take several weeks.b. False d. All of the above a. True

b. False

5. Forceps should be taped on th : 11. Electrolytic chemical markings area. Shank semi-permanent.b. Proximal end a. Truec. Handle b. False •d. Lock box Sponsoredby:

~6. Instrument taping __ gene ally a " AESCULAPpermanent marking solution. ACADEMYa. Isb. Is not

msnument Continuing Education (iCE) lessons provide members with ongoing education in the complex and ever-changing area of surgical instrum!nt care andhandling. These lessons are designed for CIS technicians, but can be of value to any CRCSTtechnician 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-certifi-cation 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 throughIAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions)

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