(This is the second 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: Refurbishment of surgical instrument trays seems like something that should be happening and scheduled as a matter of course in hospitals. It is not always the case and this may be because we are having to change the way we manage our instrument inventory, as the money isn’t there just to replace kit. If we are going to be using instruments that are 40 years old, at least they should go through some sort of refurbishment or even in-house quality checks to decide if replacement is the only option.
Refurbishment for me, is more around looking beyond the standard repairs across the tray of instruments. This should be a given that they are sent back working! The skill is in refinishing the instruments and following the finishes that are already on the instruments, to stick to the OEM ‘s desirable finish. With some of the instruments there will be a reason that a certain finish has been chosen in relation to the procedure. Manufacturers names should be retained across the instruments to preserve the original traceability of the instruments.
We are looking to proactively lengthen the working life of the instruments, so addressing potential corrosion hazards has to be addressed. It is proven that a smoother surface finish improves corrosion resistance, so manually polishing and re finishing instruments is a must. A quick cheat is to fire sandblast all over the instrument and it may look passable, but this is not a good practice when we’re refurbishing. Manual work needs to be put into refinishing the instrument and removing scratches, pits and surface damage which may otherwise spell the end of the instrument life.
Having disrupted the instrument surface, it should also be repassivated. This involves artificially creating the passive layer on the instrument, oxidising the Chromium in the stainless steel. You might also want this process validated, which can be an option and the passivation ASTM gives guidance on this.
Instruments such as artery forceps and clamps that are part of a tray going through refurbishment should also be subjected to any relevant repairs. In these sort of instrument you’ll be looking at serrated teeth on artery forceps and atraumatic teeth on clamps such as Debakeys; ensuring any burrs are removed and the jaws are repolished. The set is the key to these instruments, to ensure they work correctly vs the instrument racks. Standard artery forceps vary here in terms of where they should touch vs what rack they are held on, compared to clamps, so that should be discussed and explained by the service provider.
An issue with retractors that is sometimes overlooked is the articulation of the ratchet. For example on a weitlander retractor, in older instruments you may see that there is actually a gap where the rack is inserted into the body of the retractor; this is a perfect bug house! Some of the newer instruments are soldered, which again isn’t great, as this still allows for moisture ingress. These ratchets should be welded to fill all these gaps and avoid any decontamination misdemeanours.
The caveat with a proper refurbishment service, is that quite often the service provider may spot other issues that you didn’t know were present, so be prepared for a bit of flex on the budget. Book the instruments in for another repair the same time 6 months/next year and this will ensure the quality of the instrument inventory is sustainable, retains a good performing quality level and they’re fit for the patient.
There may be other services available as part of a refurbishment, such as laser marking. It could be a good time to put ‘Mr Brown’ on all of Mr Brown’s instruments so they don’t get mixed up or possibly add some traceability in respect of a GIAI GS1 mark.
For electrosurgery instruments, recoating is an obvious thing to do and this recoating should be adequately tested with a suitable material. Be aware that some ‘special’ rongeurs may have Titanium Nitride type coatings, which may be costly to recoat (may present gold or black); but double check this is done correctly through a process of Physical vapor deposition (PVD) and not just gold plated. PVD coatings are ultrahard and are generally on the instrument for friction resistance and performance, not just to look pretty.
One final issue which we commonly see when handling instruments sent in for repair and refurbishment are hollow handled instruments. You should be able to spot these by the weight of them. Quite often they can get holes in them and are a nice reservoir for water to be stored and not very nice to get squirted with when you’re performing repairs on them or inspecting them in the Sterile department!
Hank Balch: Nothing can be more frustrating as a customer of an instrument repair/refurbishment company than to receive an instrument set back to your CSSD/SPD with obvious quality errors still present in the tray. Surprisingly, I have seen a number of departments who are not currently reviewing these “refurbished” trays prior to them going back into service through the decontamination area, so they might not even know their current repairs are not meeting standards. Creating a workflow for your refurbished trays that requires them to undergo an internal quality assessment prior to being sent back into general inventory is a critical step to protecting your repair investments and ultimately your patients.
Connected to this, it is very important for CSSD/SPD leaders to clearly communicate your quality expectations to your repair/refurbishment vendor on an initial and on-going basis throughout your service contract. Even within the hospital setting, different customers have different expectations of what is acceptable and not acceptable for the quality and longevity of their instrument inventory. If you do not share your particular standards with your repair technician, they may make incorrect assumptions for how to serve you and your inventory well.
Finally, make it a point to be proactive in your approach as a CSSD/SPD department to identify repair issues and concerns at the point of reprocessing and inspection, rather than assuming (hoping!) these problems are caught by your team members in the Operating Theatres. The ultimate goal should be for your (operating) customers to only get fully functional, sterile instrumentation every case. How that happens is up to your CSSD/SPD team and your surgical instrument refurbishment/repair partner.