April 2007 - CS Solutions

INSIDE THE CURRENT ISSUE

CS Questions ● CS Answers

Wrapping small instruments in towels; tape on loaner sets

by Ray Taurasi

Q The SPD at the hospital I work at has started wrapping small instruments (forceps, hooks, knife handles, etc) in a towel before placing in a pan of larger instruments to be sterilized. I have always thought this was not correct, as it made too dense a package to be properly sterilized. If I am wrong, I will happily admit it, but if I am right, I need references to help plead my case.

Figure 1 - Plastic insert box

Figure 2 - Paper bag pouch

Figure 3 - Aluminum insert cases

Figure 4 – Insert case in instrument set

A It is possible to achieve effective sterilization when items are wrapped loosely in OR towels and placed in an instrument set. We also know that sterilization is a probability and to decrease the likelihood of any failures we do need to be very attentive to our packaging choices, methods, set assembly and the density of contents. Our goal should be to present the least degree of challenge to the sterilization process. Every time we add something to a package to be sterilized we increase the challenge to the sterilization process. To that end it makes sense to eliminate any unnecessary items from packages we want to sterilize.

Certain small, delicate and or sharp items added to instrument sets do require special attention, packaging and or containment. Often in the past peel pouches and or towels were used to protect and or isolate such items. AAMI guidelines, as well as those from other professional entities, like ASHCSP state that peel pouches should not be used inside of wrapped or containerized sets. The reasoning for this is that the peel pouches cannot be positioned in the proper manner to facilitate the permeation of sterilants and they are also likely to create excessive moisture. The use of towels can also be problematic leaving foreign body deposits on surgical instruments such as lint, fibers, and chemical residuals from laundered textiles.

As you also noted the use of too many towels could also create a greater density requiring an extended sterilization exposure time. There are some better alternatives to using towels such as medical grade paper envelope bag-like pouches and metallic or plastic insert cases. (See Figures 1, 2, & 3). The aluminum and plastic insert cases come in varied sizes and styles since they are rigid they provide excellent protection to delicate instruments and they prevent any sharps from puncturing through the package. The metal cases have a superior thermal conductivity, which assure thorough and rapid drying of contents. Plastic cases are more prone to moisture retention can attribute to wet loads. The insert cases are validated for effective sterilization within instrument sets (Figure 4). The aluminum and plastic cases are reusable, which makes them the most economical alternative to towels and paper pouches.

Q I work at a large hospital in the Sterile Processing Department. We get 20 to 40 loaner sets per week for different procedures such as total joints, spine cases and the like. The problem is when we receive these loaner sets from the sales representative many of the lids are covered with clear old dirty scotch tape. As the sets are being processed through the decontamination some of the techs are not taking the time to remove the tape. The instrument techs are then wrapping and sterilizing these sets with the old tape still on the containers. After being processed through the sterilizer the tape becomes dry and brittle. I am concerned that the pressure in the autoclave will cause the tape to flake off into the instruments sets, or that when the OR staff opens these trays that the brittle tape will shed off on the sterile field. How should this be corrected?

A Your concerns are legitimate. The old tape can indeed flake off and end up on surgical instruments thus finding their way into a patient’s body. Any such foreign matter can pose a risk to patient safety and welfare. The old tape remaining on containers can also be a barrier to sterilant contact and a source of increased bioburden affecting the efficacy of the sterilization process. Thorough cleaning is a prerequisite to sterilization. All debris, soil or foreign matter must be completely removed during the cleaning and decontamination process.

Tape often is very difficult to remove especially once it has become baked on after exposure to the high temperatures associated with cleaning, thermo disinfection and sterilization. The use of a permanent ink and adhesive remover may facilitate ease in the removal of such matter from containers and baskets. When using any such solvents be careful in your selection and be sure to follow the manufacturer’s instructions for use. The solvent you utilize should be environmentally friendly, non-flammable, non-explosive, non-toxic, free rinsing, PH neutral and safe for use on the intended products.

You should revise your procedures to include the necessary steps and processes to be followed when cleaning containers, and other devices, which includes the removal of all foreign matter such as scotch tape. SPD staff should be trained relative to the change in procedure and their performance must be monitored to ensure compliance and competence. You should also bring this matter to the attention of the manufacturer’s representative who provides the loaner trays to your department. Manufacturers should be providing instrument sets to you in a clean, complete and orderly manner. Loaner trays also need to be delivered well in advance to allow your staff the time to properly decontaminate, package, sterilize and deliver the sets to the OR. There are no shortcuts to proper cleaning and sterilization processes; haste leads to compromises in technique and jeopardizes patient safety and the quality of care.

Ray Taurasi is director of professional services for Case Medical Inc., Ridgefield, NJ. His healthcare career spans over three decades as an administrator, educator, technologist and consultant.