FY26 Main Campus Instrument Stewardship

Perioperative Services

Instrument Stewardship OR Main Campus

Orientation - 2026

Objectives

• Describe the steps in two-person sterility verification of instrument pans
• Identify placement of chemical indicators
• Interpret results of chemical indicators and confirm they have met the appropriate sterilization standards
• Discuss proper handling of flexible endoscopes
• Understand the importance of point of use cleaning
• Understand the importance of instrument tracking with Censitrac
• Describe instrument handling after procedures for used/dirty instruments
• Describe Instrument return for clean/unused instruments after procedures
• Understand IUSS/ONE TRAY process overview

Checking Sterility Before Use

• Verification of all indicators are made:
• Before opening the instrument set
• After opening the instrument set
• Before placing the instrument set on the sterile back table

This is always a two-person verification

External Verification- Rigid Pans

Blue filter showing

Instrument pan should be fastened and sealed

Locks should present, intact, and process indicator color changed

Internal Verification- Rigid Pans

• Once lid has been removed, release filter plate and check position of filter (paper should cover ridges on all 4 sides)
• Filter should be free of holes and moisture
• Discard filter paper
• Place filter retention plate(s) loosely in the basket with instruments at the end of the case
• Retention plates can be secured back to the lid when there is risk of damage to instruments (delicate instruments or not enough space for retention plates)

Check for damage and moisture.Moisture can consist of water standing in the bottom of the instrument pan or dampness in the set.

**If you discover moisture, foreign particles, or bioburden in a pan,do NOT use the instruments – they are contaminated.

Chemical Indicators or Integrators

• Placed on the bottom of the set, in opposite corners for large pans (small sets can have one indicator)
• On each level of a multiple level set
• Inside the popcorn bag with the count sheet
• Placed inside of the instrument roll or any other challenging area of the instrument set

Popcorn Bags

• Found in trays that have been steam sterilized.
• Pans that are sterilized by V-Pro Max or Sterrad will not have popcorn bags.

• The count sheet will be inside the popcorn bag along with an indicator of sterility.
• Integrators/indicators are placed inside one of the popcorn bags and handed off the field to the circulator.
• The circulator places the outside pan locks in the bag, writes the patient’s initials on the bag, and keeps it for the duration of the procedure.

• Once the procedure is over and the patient has left the room, the popcorn bag can be discarded.

If pans do not contain a popcorn bag, pass off indicators to circulator in another container. The circulator will gather and keep all internal/external indicators until the end of the case.

Wrapped Instruments Sterility Verification

• Check and verify color change on sterilization tape
• Package wrap intact
• Event Related Sterility issues have not occurred

• Before placement on the sterile field, the wrap must be checked for holes

• Verify that there are no visible holes, tears, or moisture before opening
• After opening verify indicators on the inside of the package are present with the acceptable color or sterilization range

Endo Instrument Containers Know the Difference!

Processing Method

• STERRAD
• V-Pro Max

Endo Instrument Containers Know the Difference!

Processing Method STEAM

This pan is Sterile!

This pan is NOT sterile!

Endo Pan Handling

• Endo pans all have names starting with “Endo”​
• At the end of the procedure, endo instruments must be placed back into the protective designated slots in the container they came from, and placed in your case cart for reprocessing

• Use Lap sponge moistened with sterile water to wipe scope
• Return scope to protective slots in container taking care to not to place anything on top of delicate scopes
• Place used scopes back in container exactly as received
• Do not put heavy items such as a light cord or rigid instruments on top of scopes

Flexible Endo Scopes

Check colored tag:

• For date on the back - this is the date when the scope must be reprocessed
• For color of the tag to assure it corresponds with the day you are using the scope.

• Flexible scopes with no pan DO NOT come in a pan instead these come in an Endoscope bucket (call ORTA for bucket if not on case cart)​
• Wear gloves when handling (before and after use)​

If you must retrieve a scope yourself:

• Assure you are using the scopes with tags that correspond to the current day
• If there are no scopes in the cabinet with the correct colored tag, use a scope for the next day color
• Please assure you are using the scope closest to its expiration date first

Nurse must scan scope into patient chart

Flexible Scope Handling After Procedure

All flexible scopes should come with a tip protector.​

• Intended to protect the scope tip in transport before and after the case

​ When the case is complete:​

• Use First Step to begin the decontamination process in the OR​
• Put the tip protector back on the scope ​
• ​Place a patient identification sticker on the colored side of the scope tag along with the time it was removed from the patient and return scope and colored tag to endoscopy for reprocessing
• Take the scope in the bucket it came in to the designated area (these do NOT go on your case cart)
• Main OR: take to the closest dirty endo room
• MCE OR: take to the dirty scope cart on the 3rd floor Skybridge

MCE dirty scope cart call 615-573-6700if dropping off a scope here from MCE

Instrument Point of Care

Wipe instruments during procedure (use lap sponge moistened with sterile water)

• Prevents overaccumulation of blood and bioburden
• Decreases possibility of missed bioburden during CSP process
• Prolongs life of instrumentation due to corrosion

Flush instrument

• Instruments with lumens should be flushed only with sterile water during surgery and post surgery
• This is done to prevent clogging and drying of the gross soil
• Saline must not be used, since the chloride ions can cause pitting and deterioration of the finish on the surface of instruments

Spray instruments after surgical procedure with enzymatic spray

• Keeps instrumentation moist during transport for decontamination process
• Reduces risk of bioburden
• Do not spray endoscopic telescopes, camera heads, light cords, or eye instrumentation

Instrument Handling After Procedure Used/Dirty Instruments

• Use the count sheet to ensure that the instruments are returned to the correct pan
• Remove all the towels from the pan
• Filters should have been checked prior to placing the pan on the back table and therefore should not be still in the pan
• Integrators, all outside load stickers (if present), and pan locks should be in the popcorn bag with the patient’s initials. This can be discarded once the patient leaves the room.
• All instruments in the pan must have box locks unlocked, be disassembled, and sprayed with transport gel
• Lock the rigid containers before placing on case cart
• Ultimate responsibility lies with the scrub person to make sure all is complete
• For the safety of everyone in decontamination, remove all sharps & clamp inserts

Sterile, Unused Instrument Return Process

If you do not use a pan (i.e., it is still sterile - all external indicators are intact, and the pan is unopened):​

• Place on a prep stand outside your room and ask an ORTA to get it, or​
• Return it to the nearest Clean/Unused Instrument Pan Return cart (one located in each staging zone: Main 1, Main 2, Main 3, Robotic, MCE North, MCE South, and 4 South)

When returning the pan to the Clean/Unused cart:​

• Place the instrument on the case cart​
• Log into Censitrac on the workstation ​
• Scan the location barcode on laminated sign​
• Scan the returned instrument pan​ barcode
• Then scan the wall barcode again to “send” the scanned data ​(meaning Censitrac captures the pan’s new location)

Censitrac Scanning

Did you pull an instrument pan from the shelf to use in your room? It must be scanned in Censitrac, so the location of the pan can be tracked along with the patient upon whom it was used.

Choose Workflow

To log on, click the icon on the desktop

Scan Case Barcode

Scan your badge barcode

Scan room location.

Dont't Forget to click "Send Scanned Data" or scan room location again

Located on workstation computer or outside room door

List of Quality Events

Censitrac Quality Feedback

Any time there is an issue with an instrument or pan, please provide Quality Feedback in Censitrac. This provides paper documentation for instrumentation issues.

Located on your count sheet on bottom of paper

Be specific

Repair Tags

How can you repair something if you don’t know what’s broken?

• Use Repair Tag for instruments or pans that need repair or are broken
• Use a sharpie and provide a DETAILED description – not “broken” or “doesn’t work”

Why use Repair Tags?

• Quick & easy to secure
• Can be applied to all instruments
• Best of all, can stay with the instrument and go through the instrument washer!

**A Censitrac Quality Feedback Report must also be completed**

Censitrac

Looking for an instrument pan? Censitrac will show you where to find it!

• oneSOURCE is the source for the most updated information on cleaning, decontamination, and sterilization guidelines for Sterile Processing, Infection Prevention, and Decontamination of reusable surgical instruments, medical devices, equipment, and implantable biologics, materials, and devices.
• If asked during a survey, you will need to demonstrate how to find this resource.

One Tray-IUSS

• After sterilization, ONE TRAY provides for the safe transport and assure delivery for immediate use.

• This process uses a sealed container with tamper evident security and load record documentation according to AAMI and AORN guidelines.
• The performance and intended use of the ONE TRAY Sealed Sterilization Containers should utilize the device manufacturer's sterilization exposure parameters and recommended practice guidelines such as those by AAMI (Association for the Advancement of Medical Instrumentation) or AORN (Association of periOperative Registered Nurses).

• ORTA's are responsible for a immediate-use steam, sterilization, IUSS and documentation of the process.

• IUSS is for emergent situation only and is not to be used as a substitute for insufficient instrument, inventory.

• View chemical indicator for sterility prior to introducing to the sterile field.

• Ensure ample cooling time before use of sterilized item to avoid burning the patient.

• Per the sterilization practice processes SOP, IUSS for implantable devices is prohibited except in emergent situations.

Immediate-Use Steam Sterilization (IUSS)

IUSS is not performed on the following devices :

• Implants, except in a documented emergency situation when no other option is available.

• Approval of IUSS of implantable device is obtained by perioperative leadership (e.g., Operating Room Director) and surgeon.
• An Early Release Form is completed with appropriate signatures.
• Sterilization information is collected and includes sterilizer load, biological lot number, results of the biological, and patient information.
• An occurrence report is entered into VERITAS, outlining the situation.
• The Early Release Form is uploaded to the veritas event filed.
• Post-procedure decontamination of instruments used on patients who may have Creutzfeldt-Jacob Disease (CJD) or similar disorders.

• Devices or loads that have not been validated with the specific cycle employed.​

• Devices that are sold sterile and intended for single use only.​

References

AORN Essentials Sterile Technique. Opening Sterile Packaging Systems. https://www.aorn.org/essentials/sterile-technique

VUMC Policy: Sterile Processing: Sterilization Practices. https://powerdms.com/link/VanderbiltUMC/document/?id=2354749

VUMC SOP. High Level Disinfection: Modified Flexible Endoscopes Reprocessing https://powerdms.com/link/VanderbiltUMC/document/?id=2354785

VUMC SOP. Immediate-Use Steam Sterilization IUSS. https://powerdms.com/link/VanderbiltUMC/document/?id=2354806

VUMC SOP. Point-of-Use Instrument Cleaning and Spraying Compliance. https://powerdms.com/link/VanderbiltUMC/document/?id=2354774

VUMC SOP. Preparation and Transport of Sterile or Soiled Instruments, Medical Devices, and Endoscopes https://powerdms.com/link/VanderbiltUMC/document/?id=2585540

DisposableThese are not saved for other uses!

ReusableDo not throw these away!