(This is the first installment of a short series of articles focused on surgical instrument quality, repair, and refurbishment from the perspective of a UK instrument manufacturer and repair professional [Daniel Coole] and a US sterile processing consultant [Hank Balch]).
Daniel Coole: Would you stir you coffee with this (surgical instrument)? I love this question as it is the ultimate instrument performance, cleanliness and hygiene test. The answer should be yes every time, but the challenge is much broader.
The challenge for covering this topic is the amount of stakeholders involved in direct/indirect usage of the instrument and an interpretation of when an instrument can still be used. There needs to be a reasonable understanding across the stakeholders as to what the device is used for, how it is used and the basic of how it works, which can generally be backed up vs the usage intended.
I had a rather heated exchange with a customer a few years ago, over what should have been a beautiful Metzenbaum dissecting scissor; the customer worked in the sterilisation department as an administrator. I was trying to explain to them that the scissor that we returned as unrepairable, was unrepairable because it was over ground and therefore could not perform for the purpose it was designed for.
It also had a super cut edge omitted from the edge, so not only would the scissor not cut along the whole blade, but it would not have the grip and cut of the micro serration/sharpened edge that the scissor was designed for. The response from the customer was “these are just basic scissors and we feel this scissor is still acceptable for use”. My next question was how the customer would feel if this was used on a family member. The clinician chose that scissor because it is required to perform a crucial element of surgery and it must perform as it was designed through its lifetime.
I have since learnt not to get involved in emotional exchanges such as this, but when you have passion for doing things right it is hard to swallow. My view was from the perspective of the patient and the clinician using the scissor, rather than making a quick buck with a poor repair, which we see too much. A responsible repairer should be prepared to say that an instrument cannot be repaired safely. However, this does require those technicians having the education and often having manufactured those devices, which is nowadays rare.
On the other hand, I can see that resources are tight and when there is an option that is perceived as being acceptable and it means getting the scissor back on the tray, it is an attractive option. So who is right? Surely the outcome which means that the patient gets the best surgery, quickest chance of recovery and no infection has to be the best option.
Industry must work together for the benefit of the patient. Hospitals/3rd party sterilising/repair companies need to share education materials and trust each other. It’s not all about commercial gain and if something is beyond repair, understanding why and getting a reasonable explanation for that should be enough.
The scissor is a great visual for a repair, however when looking at useful life for an instrument the surface of the device is often overlooked. Pitting on instruments that are still functional mean that the device should no longer be used, but this pitting is not always easy to see or to identify. Corrosion can easily effect other instruments too, so what seems like a minor issue can quickly spread and cause problems elsewhere on a tray.
For all the additional work that will come from the MDR in Europe, part of this is the up classification of Class I instruments to Class IR. This requires not only validated reprocessing instructions but also suitable advice around in situ testing for devices. Although this may be more appropriate to functionality testing, surface changes should also be part of this. Instrument manufacturers will have to look for practical tests that can be performed to prove devices are still functional. We can look to British Standards potentially for solutions and the MDR will help to develop the education of Sterile processing departments around instruments. The Reprocessing instructions should be getting a lot more detailed!
Hank Balch: As SPD/CSSD users, we know the very tension that Daniel Coole mentioned in the section above. Budgets are tight, surgeries are already on the schedule, and we’re confronted with a grey area of a specialty instrument on the edge of instrumental life & death. Do we take our last pair of Dr. Johnson’s favourite scissors off life-support, or put them back in the tray for just one more cycle? If it works, we’re heroes – cost efficient and productivity oriented. If it fails…well, let’s not get caught up in “What ifs…”, right?
In confronting these hard questions, start with the simple answers and work your way backward. If a scissor blade is cracked or a tip broken off, this should trigger an immediate removal of that instrument from the tray, and it should be immediately segregated in your department as “Beyond Repair.” There is no use sending a pair of DeBakey forceps to a repair van or off-site lab if they have been broken in two by a frustrated surgical or completely worn out through years over-use and lack of repair. These kinds of clear thresholds, while sometimes obvious, should be a part of technician on-boarding and continuing education.
Many of the grey areas of this discussion can be addressed through targeted education for each instrument category for your nursing and frontline surgical instrument reprocessing staff. Identification of instruments is the foundation of our jobs, and functional testing is becoming more and more a central focus, but knowing the signs of “instrument death” is an area that can further protect your patients, guard your inventory quality, and reduce frustrations for all members of the surgical team.