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LEARNING OBJECTIVES:

1. Discuss differences in instrument quality.


2. Describe the process to correlate surgical set contents with count sheets.
3. Explain ve inspection factors used to select appropriate instruments.
Instrument Quality
Surgical-grade instruments are required in
all surgical sets because they are designed
and manufactured to strict specications
from high-quality stainless steel. They are
subjected to quality control inspections at
several points during the manufacturing
process. These instruments are less likely to
fail after repeated uses and should cause no
tissue damage related to their construction
and nishing. Surgical-grade instruments,
if properly handled, cleaned and sterilized,
will provide years of useful life. In contrast,
oor- (lower) grade instruments may have
a similar design, but their specications
for steel quality and manufacture are less
stringent. For example, on inspection of
new instruments, one may discover nicks
and burrs, and instrument tips and jaws may
not meet perfectly. Using these instruments
in a delicate surgical procedure can lead to
unintended tissue damage that, along with
the need for tissue repair, increases the
potential for poor healing, infection and
increased recovery costs.
Disposable and oor-grade instruments
should not be placed in an ultrasonic
cleaner or surgical sets with surgical grade
instruments because doing so can cause
metal changes due to ion transfer. These
changes, in turn, alter the reaction between
the metal and chemicals used for instrument
cleaning, disinfection and sterilization.
Resistance to staining, pitting and rusting can
also be compromised. Once these problems
occur, even surgical-grade instruments can
be compromised, and they will no longer be
appropriate for use in surgical instrument
sets.
Knowledgeable CIS technicians effectively
manage instrument ow and correctly
handle instrument sets to maintain their
high quality. Their education and skills
protect patients and the signicant nancial
investment made by their facility to have
surgical-grade instruments available.
Instrument Set Contents
Contents of instrument sets are usually
determined by the surgical team. Input about
the type and number of each instrument to
be available in designated sets is generated
from the surgeons, surgical team members
and operating room managers. The names
and numbers of instruments used in specic
sets vary between facilities. Examples
include biopsy set, plastic set, minor
set, or soft tissue sets that include
all basic instruments to perform a breast
biopsy, inguinal hernia, or other small
(shallow) procedure. The specic set name
and number of instruments it contains is
not important. The ultimate concern is to
provide the customer (surgical team) with
what is needed in a timely manner.
Trained CIS technicians can assist in
gathering specic information for each set
and the instruments it contains. They should
Instrument Selection for
Surgical Sets
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CIS SELF-STUDY
LESSON PLAN
LESSON NO. CIS 219
(Instrument Continuing Education-ICE)
Instrument Continuing Education (ICE)
lessons provide members with ongoing
education in the complex and ever-changing
area of surgical instrument care and handling.
These lessons are designed for CIS technicians,
but can be of value to any CRCST technician
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-certication 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 through IAHCSMM or Purdue
University; IAHCSMM accepts only online
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LESSON PLANS
Surgical Services is the largest volume customer of Central Sterile Supply Departments and the
need for accuracy in assembling required instrument sets cannot be over-emphasized. Thousands
of instruments pass through the hands of knowledgeable Certied Instrument Specialist (CIS)
technicians each week. Their skills in processing and maintaining instruments have a direct
impact on the quality of care each surgical patient experiences. This lesson highlights the skills
necessary for the appropriate selection of instruments for basic surgical sets.
Lesson Author
Carla McDermott, RN, ACE, CRCST
Educator
South Florida Baptist Hospital,
Lakeland, FL

IAHCSMM
CIS Self-Study Lesson Plan
also follow a written process describing
required procedures when an instrument
is damaged or missing. It should include
details about who should be notied, how
replacements are obtained, who should be
notied if a replacement is not immediately
available, and whether the set can be
packaged and sterilized without the missing
item. When an incomplete set is approved
for sterilization, it must be labeled so the
user knows about the missing instrument
before the surgical procedure begins. For
example, the instrument may be critical for
a specic procedure or surgeon, but not for
all procedures or surgeons.
CIS technicians processing instrument sets
should have the following information
available for each instrument in the set:
the manufacturers name and catalog
number (to help with identication and
replacement)
its length and weight
the facilitys specic name for the
instrument if it is different from that
used by the manufacturer. Note: The
use of unique instrument names can
be frustrating for inexperienced CIS
technicians and sharing this information
in the instrument manual or library is
helpful.
the number required
Instrument set count sheets are created
from the above information. Instruments
are typically listed on the count sheet in the
order the surgical team expects them to be
assembled. This promotes continuity and
allows the operating room team to quickly
count them. Therefore, when stringers or
pin trays are utilized, instrument assembly
should follow the count sheet order. The
surgical team depends on the consistent
assembly of sets to streamline surgical
procedure set-up and preparation.
A typical order of instruments requested
by the surgical team might be as follows:
Criles Kellys Allis Babcocks Kochers
scissors needle holders sponge sticks.
This set-up should be consistently followed
unless a formal change is agreed upon.
Over time, requirements about the types and
numbers of instruments in a set may change.
They can be suggested by surgical or CSSD
personnel, but changes should be approved
by a consensus of both departments.
Instrument set changes should also be
approved by supervisors and/or managers
from both departments, especially if
instrument budgets will be impacted by
the proposed change. For example, the
purchase of all gold-handled needle holders
for use in every set might be the dream of
all the OR team members, but not a viable
option for the managers. Information must
be shared with all team members in both
departments before any change is made,
documented on the formal count sheet,
and then implemented. It is also helpful to
destroy all previous versions of the changed
count sheet to avoid any communication
problems.
Instrument Selection
The determination of instruments for a
surgical set involves making selection choices,
unless the count sheet is driven by instrument
catalog numbers. While the catalog number
method assures exact selection of identical
instruments, the potential for changing
purchasing contracts may make this method
impossible or, at best, inefcient. Alternately,
CSSD personnel frequently use some key
selection factors to ensure that each type of
instrument:
is of surgical-grade
is the same length
has identical tips
is matched in weight (examples: Pediatric,
Plastic, General, and Orthopedic)
is in good working order
Another issue concerns the relative size of
different instruments. For example, when
using a 7 scissor, a 7 needle holder
and 7 forceps should also be available.
Needle holders should also match each
other if two like sizes are requested in the
set. This becomes a challenge when mixing
newer and older needle holders. One little-
suspected concern involves matching needle
holders with tungsten carbide (TC) inserts.
Rejuvenating needle holders by replacing the
TC inserts also requires smoothing the newly
joined edges, and this removes a minimal
amount of the original needle holder jaw/tip.
Over time, a Mayo-Hegar needle holder with
TC inserts may have a tip that resembles a
vascular needle holder. The catalog number
may indicate a Mayo-Hegar needle holder,
but it does not match a newer instrument.
Working with the surgical team, appropriate
placement for this usable needle holder can
be determined. Then suitably labeling the
individual instrument will assist in proper
placement each time it is processed.
Several lengths of the same instrument may
be requested to provide the surgeon with
an appropriate working length instrument
throughout the surgery. For example, longer
needle holders and forceps work well in deep
body cavities, but they can be cumbersome
when closing the fascia layer or skin. For this
reason, thumb and tissue forceps in three
lengths are not uncommon for a major
abdominal set. CIS technicians know that
it is important to provide matching length
pairs when pairs are requested.
The matching of instrument working tips
is important to surgeons. The photos
that accompany this lesson demonstrate
differences in several instruments. Technically,
they are all known as Babcocks. However,
they are of different styles or from different
manufacturers and, while the differences
may seem insignicant, they can have a
detrimental effect on human tissue. Notice
the difference between the Babcocks that
are shown.
Babcock forceps are used to hold bowel tissue.
These are not a matching pair. Notice the differences
in length, weight, and width of gripping surface.
The clamp is used to securely hold bowel tissue
during a bowel resection, and the repair can
be hindered if the tips do not match because
the tissue can slip when unequal grasping
pressure is applied to all edges. Then a slip
from this clamp could cause bowel contents
to be spilled in the abdominal/peritoneal
cavity, and this contamination may cause an
infection that increases pain, healing time,
and expense for the patient. Allis and Kocher
clamps offer a secure hold on tissue when
traction (pulling) is required. When used in
pairs, if one tip has a smaller bite or fewer
teeth, it can tear or slip off the tissue. Human
tissue damaged in this way does not heal
well, and once again patient care has been
compromised.
Kochers are used to hold fascia, ligaments and
cartilage. These are not a matching pair. Notice the
differences in length, weight and size of teeth.
Retractors are vital in providing adequate
working space and visualization of the
operative site for the surgeon. The availability
of matching sizes and styles helps meet
their needs while protecting the tissue that
is retracted. To hold the incision open, equal
forces of traction and counter-traction applied
by either handheld or self-retaining retractors
are required. If the retractor blades or points
do not match, tissue damage can result, and
tissue healing problems can occur. Retractor
blades must, therefore, be inspected for
damage.
Handling and packaging procedures are
important in properly maintaining surgical
instruments. Nicks or burrs along blade
edges can tear the tissue needed to heal
incisions. Retractors with pointed tips also
require inspection for burrs and broken tips.
Note: Gelpi self-retaining retractors are used to hold
an incision open to expose the operative site. These
are not a matching pair. Notice the differences in size
and curvature.
This kind of damage is more often caused
by mishandling than misuse. Gelpi retractors
are self-retaining, and they are frequently
used in pairs. When they are, their length,
handle width and blade curvatures must
match or unequal pressure will be applied to
the incision lines. If one tip is broken, it will
not hold in place, and the instrument will slip
across the cut edge of the incision. Damage
to adipose (fat) tissue can result and impair
wound healing. Skin hooks are handheld
pointed retractors, and they provide another
example of the importance of inspection.
If their points do not match or if the tips
are damaged, they can puncture the skin,
and compromised skin edges do not heal
smoothly. These examples should conrm
that even the simplest surgical instruments
require thorough and accurate inspection.
Summary
Efciency and speed can save lives in the
operating room. A CIS technician does
everything possible to ensure that the correct
matching instruments in good working
order are available when needed. Teamwork
between the users and CIS technicians
will help ensure a consistent work ow.
Dedication of everyone on the healthcare
team helps to ensure the patient has the best
care and outcome possible from their surgical
experience. As a member of this team, the
CIS technician truly is instrumental to patient
care.
Resources
Central Service Technical Manual. Seventh
Edition. Chicago, IL. International
Association of Healthcare Central Service
Materiel Management. 2007.
Lind, Natalie. Instrument Specialist
Course. Identication, Handling, and
Processing Surgical Instruments. Chicago,
IL. International Association of Healthcare
Central Service Materiel Management.
2005.
Loo, V. and McLean, P. ASC Surgery:
Principles & Practice. Infection Control in
Surgical Practice. 12/2005.
Surgical Technology for the Surgical
Technologist. Delmar Thompson Learning.
ISBN-10: 0766872921.
The author wishes to thank Clif Morley,
CRCST, at South Florida Baptist Hospital,
Plant City, FL, for his assistance in preparing
the photos used in this lesson.
IAHCSMM
CIS Self-Study Lesson Plan
Technical Editor
Carla McDermott, RN, ACE, CRCST
Educator
South Florida Baptist Hospital,
Lakeland, FL
Series Writer/Editor
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI
CIS SELF-STUDY LESSON PLANS
IAHCSMM is looking for volunteers to write or
contribute information for our CIS Self-Study Lessons.
Doing so is a great way to contribute to your own
professional development, to your association, and
to your Central Sterile Supply Department peers.
Our team will provide guidelines and help you
with the lesson to assure it will be an enjoyable
process. For more information, please contact
Elizabeth Berrios (elizabeth@iahcsmm.org).
CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
Lesson No. CIS 219: Instrument Selection for Surgical Sets
Questions (circle correct answer):
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LESSON PLANS
1. Surgical-grade instruments are
interchangeable with most oor-grade
instruments.
a. True
b. False
2. One advantage to surgical-grade
instruments is how long they last.
a. True
b. False
3. Stainless steel is the same no matter
how it is manufactured.
a. True
b. False
4. Mixing disposable, oor-grade, and
surgical-grade instruments in an
ultrasonic cleaner is an acceptable
practice because this saves valuable time.
a. True
b. False
5. Surgical instrument sets should follow
a pattern of assembly determined by
the most experienced CIS technician.
a. True
b. False
6. The use of manufacturers catalog
numbers makes the reordering of
replacement instruments easier.
a. True
b. False
7. When an instrument is missing, it is
important to leave a note for the
supervisor and then sterilize the set
as usual.
a. True
b. False
8. Following the count sheet exactly is
vital to good patient care.
a. True
b. False
9. Babcocks are used in bowel surgeries.
a. True
b. False
10. Kochers are used to hold fascia, ligaments
and cartilage.
a. True
b. False
11. The inspection of instrument tips is time
consuming and usually unnecessary.
a. True
b. False
12. Working with the surgical team to
select appropriate instrument sizes
provides better patient care.
a. True
b. False
13. Needle holders with TC inserts can
create a matching dilemma.
a. True
b. False
14. Gelpi retractors are handheld retractors.
a. True
b. False
15. The proper processing of surgical
instrument sets helps to ensure quality
patient care.
a. True
b. False
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