Heavy trays, towels and moisture (Part 2)

June 24, 2022


 “For our heavy pans (e.g., total pans), we have always placed a surgical towel under them for protection and to reduce wetness in the trays. We also noticed stains on the towels. Why is that?”


 If you recall last month’s Part 1 article, we addressed how to solve moisture management and surgical towel issues. This month, we’ll focus on staining problems found on the towels.


An article in IAHCSMM Communique called “Troubleshooting Instrument Stains” states, “To test for rust or stains resulting from the sterilization process, place a white sheet across the sterilizer rack, and process the load in the normal manner. Then, determine if the towel sheet contains stains or debris. If either is present, it is most likely coming from the steam lines and/or chamber walls.”1

In January 2018, the Medical Center rescheduled some surgical procedures after discovering discoloration on white tray liners in some of their sterilization packages. The facility found zero evidence of patient harm and is rescheduling the surgical procedures, “out of an abundance of caution,” the statement added.2

A study conducted by Dr. Charles Gerba, Ph.D. (professor of microbiology at the University of Arizona) and his colleagues, with support from Kimberly-Clark Corp., (Irving, TX) was published in American Journal of Infection Control (October 2013). They found 93 percent of laundered towels/reusable hospital cleaning towels—used to clean rooms—contained bacteria (microbial contamination) that could cause healthcare-associated infections (HAI). Although most hospitals have stringent disinfecting practices in place to combat HAIs, this study showed they do not sufficiently remove all viable bacteria, including:

E. coli

• Total coliforms– (bacteria that indicates fecal matter)

Klebsiella– (causes pneumonia, UTIs, and other infections.

As a result, an estimated 1.7 million HAI cases are reported annually in the U.S of the total number of soak buckets containing disinfectant, 67 percent contained viable bacteria, including spore-forming bacteria and coliform bacteria.3

Experience has shown that most staining and spotting problems (regardless of if on an instrument or tray liner) are more geographical in nature, due to such factors as:

• Water pH

• Detergent residue

• Boiler compounds in water lines

• Certain chemicals incompatible with stainless steel on instruments/surgical trays.

Any stain/color needs to be investigated. However, some experts have stated–out of all the concerns–one must look at the water and steam quality, which are generally the main sources of stains/colors. It is the reaction during the steam process that makes these “stains/colors” appear because they were not there before they were sterilized. Thus, suggesting water and steam quality.

Think about this. My friend, Richard Schule (personal communication, many times) has said, “If it is in your water or steam (poor quality), it will appear or react with your equipment or medical device and can cause poor outcomes.”

Make sure if you are using a surgical towel, it is not causing issues associated with staining or infections. Also, make sure the IFU for that towel states it can be used to line a surgical tray or a sterilizer cart. If not, I would not use them.

As noted, protection is a main reason. Many times, auditing the practice reveals tearing is a human factors issue (both by staff in the reprocessing area and by the user), as surgical trays are taken out of case carts or any shelfing unit. Staff should lift but they drag and pull, and these actions cause snags, tearing, and holes in the sterile barrier. Sometimes, regardless of the products used to prevent these breaks in the sterile barrier, it is a training issue and doing our due diligence is the only way to reduce these concerns. No product can totally prevent these concerns when staff do not do the right process in transportation of sterile barriers and removing them from a location.

You can use corner protectors to reduce tearing and line your wire sterile shelfing with a shelf liner, just a few suggestions to reduce tearing.

My suggestion—work with a manufacturer that designs products for lining surgical trays and sterilizing carts and can help audit your practice. I personally frown upon using surgical towels as a liner because that is not their original intended use.

1 Seavey, Rose (MBA, BS, RN, CNOR, CRCST, CSPDT President/CEO of Seavey Healthcare Consulting). (2015). Nursing Lesson Plan 610: Troubleshooting Instrument Stains. Communiqué, July/August 2015. www.iahcsmm.com. Retrieved April 12, 2022 from https://kipdf.com/queue/reviewing-instrument-investigation-of-staining-should-include-reviewing-instrume_5ae2fd9a7f8b9a5f348b45d5.html.
2 Lynch, Kaley. (2018, January 23). Buffalo VA has rescheduled some surgeries due to discoloration in sterilization packages. WIVB 4 [CBS Affiliate, Buffalo, NY]. Retrieved April 12, 2022 from http://wivb.com/2018/01/23/buffalo-va-has-rescheduled-some-surgeries-due-to-discoloration-in-sterilization-packages/.
3 Sifuentes, Laura Y. (Ph. D)., & Gerba, Charles P. (Ph. D)., & Weart, Ilona. (BS)., & Engelbrecht, Kathleen (MS)., & Koenig, David W. (Ph. D).  (2013, October 1). Microbial contamination of hospital reusable cleaning towels. American Journal of Infection Control, 41(10), 912-915. Advance online publication (2013, March 25). https://doi.org/10.1016/j.ajic.2013.01.015.