Motorized handpieces¹

This self-study lesson addresses the processing of instruments powered by electric motor, compressed gas (pneumatic) and battery. The size, compactness and design complexity of these devices range dramatically, from drills that are used on the tiniest ear bones to the drills and saws used on the largest leg bones. Motorized handpieces have greatly reduced the brute force historically required in orthopedic surgeries. These technological advances have also decreased the time required to perform these surgeries. This has, in turn, significantly decreased patient pain and healing times. 

The marvels of motorized handpieces have expanded the range of surgical procedures; this technology has also dramatically increased the difficulty in cleaning, decontaminating and sterilizing these devices. Surgical techniques continually evolve, and surgical instrumentation has kept pace with the age of technology. The surgeons’ ability to diagnose, treat and cure disease drives the need for evermore sophisticated instruments to achieve those goals. 

Objective 1:

List common types of motorized handpieces.

Common types of motorized handpieces include:

• Dermatomes/dermabraiders for harvesting skin grafts or reshaping skin surfaces.
• Cebatomes for removal of bone cement.
• Sternal saws for splitting the sternum to perform open heart surgery.
• Dental drills for reconstructive work on teeth and jawbones.
• Micro drills for reshaping middle ear bones or driving very small wires through bones.
• Wire drivers, drills and saws in appropriate sizes and shapes to work on the smallest to the largest bones.

Occasionally the biomedical engineers who design instruments challenge the abilities of central service technicians to clean, disinfect and sterilize their technological wonders. Engineers and manufacturers are now becoming more aware that their products are hazardous if they cannot be adequately processed to provide the surgeon a sterile instrument. 

Objective 2:

Review special processing issues for motorized handpieces.

The common thread running through all these products is their highly complex and fragile nature. For example, drills and saws have motorized handpieces that must never be submerged in any fluid. The materials used to construct these instruments are varied, which makes the selection of cleaning and disinfection products critical. Compatibility of materials and effectiveness are both issues in this selection process. The manufacturers’ recommendations must be followed to prevent damage to the instruments. Collectively, these instruments have an array of lumens, channels, attachments and multiple moving parts that pose a severe challenge to the cleaning, disinfection and sterilizing processes.

Technicians must also take great care to protect themselves during processing because, by design, these products must be processed manually. The potential for accidental exposure to blood and body fluids is high. Manufacturers must validate (prove effective) appropriate high-level disinfection and/or sterilization methods for each instrument (system) they sell. To avoid damage to the instrument and liability for ineffective processing procedures, manufacturers’ recommendations must always be followed. Specific training is required for each piece of equipment to assure that the technician can safely and properly process the item.

Objective 3: 

Describe three common power sources for motorized handpieces.

Power sources for surgical instruments are of three types:

• Electricity – Instruments powered by electricity require a cable that can be sterilized. One end attaches to the motorized handpiece on the surgical field; the other end attaches to either a motor or an electrical adapter that plugs into a 110v electrical outlet. Cables require routine maintenance involving disassembly, cleaning and lubrication. Central service technicians require additional training and tools to perform these tasks. During processing, it is imperative that fluid does not enter the cable or handpiece. Most manufacturers recommend connecting the cable to the handpiece during processing to help prevent damage from the fluid.
• Pneumatic – Instruments powered by compressed gas require a hose that can be sterilized. One end attaches to the motorized handpiece on the surgical field; the other end attaches to a source of compressed air. This source may be a stand-alone cylinder with a pressure regulator, or it can be “piped in” by a wall- or column-mounted regulator panel. The different types of powered instruments require different operating pressures, and it is helpful to maintain a chart of these pressures where the instruments are processed. Testing the instruments at an improper pressure could severely damage the instruments and injure the operator. The hoses must be inspected for cuts and other incidental damage. Air hoses must be pressurized to inspect them properly, which requires an air source in the processing area. Any damage, bubble or “bleb” in the hose casing requires that the hose be removed from service. During processing, it is imperative that fluid does not enter the hose or handpiece. Most manufacturers recommend connecting the cable to the handpiece during processing to help prevent damage from the fluid.
• Battery – Instruments powered by battery are the least cumbersome system for users. The battery seats into the instrument, which is then free to maneuver across the sterile field. This freedom of movement, however, comes with a price. The batteries require charging, which requires increased handling. Batteries and chargers are specific to each system and are not interchangeable; using the wrong ones could damage the instrument. Additional space to accommodate the chargers also creates an expense. They can be sterilized in steam, but will be damaged if submerged in liquid. 

Objective 4:

Explain the need for special care when processing motorized handpieces.

Motorized handpieces require gentle care. They cannot be dropped or knocked around and continue to work properly, and most will not tolerate submersion in any liquid. This restriction (no submersion) adds to the difficulty and potential danger involved in cleaning and disinfecting handpieces. They must be processed manually. This requires the technician to exercise great care while handling them and to meticulously clean the items, for their own protection as well as that of the patient. Technicians should use the appropriate personal protection equipment throughout the cleaning, disinfection and testing processes. Because these instruments cannot be submerged, activating these items to test and lubricate them carries the potential to aerosolize internal debris and cleaning chemicals. Technicians must use great care from the time they receive the instruments through packaging them for sterilization. 

Biohazardous debris is not the only danger when handling these items. By design, these instruments hold blades, drill bits or burrs designed to cut bone. They are occasionally returned to central service with these cutting devices still intact. The technician’s education should include how to safely disarm these devices. Many of the instruments have hollow channels that are impacted with bone chips sharp enough to puncture gloves. To avoid injury, technicians need to use great care, in addition to using personal protective equipment (PPE). Technicians should not use a k-wire or Steinman pin to dislodge impacted bone or debris from drill channels; serious injury can result. Always use the appropriate size (diameter and length) of cleaning utensil.

Objective 5: 

Relate generic processing procedures for motorized handpieces.

The following basic steps for manually cleaning and disinfecting motorized handpieces are listed to demonstrate the complexity of the process. Refer to the manufacturers’ guidelines for complete details and recommendations for processing specific handpieces.

• At the point of use (and immediately after use), remove all bits, burrs and blades from attachment devices. Remove the attachment device from the handpiece and disconnect it from the power source.
• At the point of use (including during use), remove as much tissue debris as possible with a sponge that has been moistened with sterile water. Do not use saline for this purpose because it will corrode and damage components of the handpiece.
• Separate simple devices (those with no internal mechanisms) that can be soaked and cleaned with other surgical instruments (for example, holding devices and burrs) before processing. 
• Handpieces should be attached to the hose during cleaning to prevent solutions from entering the motor.
• Clean the exterior with a germicidal detergent that has been recommended by the manufacturer. Use a soft bristle brush. 
• Pay special attention to any recessions and moving levers, switches and controls. Move them several times to assure that they have been thoroughly cleaned and that they operate smoothly.
• Clean recessions and cannulas using the appropriately sized (diameter and length) stiff bristle brush.
• Clean, rinse and inspect the hose, cable or battery pack. Inspect for signs of damage or excessive wear.
• Lubricate the handpiece with the prescribed type and amount of lubricant as recommended by the manufacturer.
• Dry all components with a soft, lint-free cloth.
• Some manufacturers recommend operating handpieces, to assure proper functioning and for dispersal of lubrication (if added), prior to packaging for sterilization. This may require secondary sources of power in the processing area. 
• Package and sterilize the unit as recommended by the manufacturer. Special racks or positioning devices may be needed for two reasons: To assure that all surfaces of the device are properly exposed to the steam and to assure that condensation does not collect in recessed or cannulated areas. (Damage to the device can result when condensation accumulates in these areas.)

Another related challenge is managing the processing of attachments and accessories for motorized handpieces. These are not interchangeable between systems, and some are not even interchangeable within systems. Few healthcare facilities have the luxury of owning saws and drills of the same make and model. Many central service departments struggle with several makes and generations of models which may not be interchangeable.

Education is vital to positive patient outcomes. The department’s emphasis on quality is quickly affected when, for example, a surgeon encounters bone chips when trying to load a k-wire or when she opens a sternal saw, and the blade guard is missing. Patients in these scenarios are placed at a great risk. 

If a department has more than two saws or drills, education specific to each is required to assure that proper care, handling and processing is done consistently. Barcoding the components of each set would be ideal. If that option is not available however, other tools can be used. Having a photo album, with a parts list, available at each work station for each make and model set being processeds would be very helpful. Charts can be posted in strategic locations, listing:

• Specific recommended cleaning and disinfecting solutions.
• Proper diameter and length of cleaning brushes.
• Proper operating pressures (for pneumatic devices).
• Devices that require lubrication and appropriate type of lubricant.
• Recommended sterilization and drying parameters.

When the photo album and charts are originally developed, and when they are updated, remember to provide this information to all locations where processing takes place. This effort is intense, but the payoff is tremendous.

Objective 6: 

Recognize that preventive maintenance schedules relate to frequency of use.

Remember that motorized handpieces are very delicate and expensive. They require the most gentle care. Proper use and handling, coupled with regular preventive maintenance and service, will assure that the devices are available for use as needed. Like most mechanical devices, routine maintenance is required. 

Schedule preventive maintenance and refurbishing based on use of the devices. Be sure that the schedule is realistic and adhere to it. For example, a cebatome might be used three times a year and may not need to be refurbished for three years. By contrast, a sternal saw that is used 45 times a month will need preventive maintenance monthly and refurbishing semi-annually. 

Utilize input from the operating room manager, biomedical engineer(s) and the manufacturer to determine the best schedule of preventive maintenance for all devices. Additional insight might be gained by reviewing repair records to determine if more effective preventive maintenance or refurbishment could save repair costs.

Conclusion

Surgical techniques will continue to evolve. This, in turn, will require changes in surgical instrumentation. A quick look back affirms that instruments have become more complex as technology responds to the needs and abilities of the surgeons who use them. Central service technicians are vital members of the healthcare team and are responsible for proficient cleaning, disinfection and sterilization of these specialized instruments. To do their jobs effectively, they must keep pace with these changes.

Endnote

1. This lesson is adapted from: Rick Schultz and Carla McDermott, “Surgical Instrumentation” (Chapter 11), in: Jack Ninemeier, Editor. Central Service Technical Manual. Sixth Edition. Chicago, Illinois. International Association of Healthcare Central Service Materiel Management. (In process). 

HPN

Advisory committee for self-study lessons

Anne Cofiell, CRCST
Cofiell Consulting Services
Mt. Laurel, NJ

Charlie Hancock, BSEE, MBA
Charles O. Hancock Associates Inc.
Fairport, NY

Susan Klacik, BS, CRCST, ACE, FCS
Sterile Processing Manager
Forum Health
Youngstown, OH

Richard Schule, BS, CST, CHMMC, FEL
Manager
Surgical Processing Department
The Cleveland Clinic Foundation
Cleveland, OH

Technical Editor and Lesson Author
Carla McDermott OR/RN, CNOR 
Osceola Regional Hospital
Kissimmee, FL 

Series Writer/Editor 

Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI

February