Instrument care takes on greater importance in toxic anterior segment syndrome era

September 15, 2008

In the age of toxic anterior segment syndrome, proper care of ophthalmic surgical instruments is of even greater importance to patient safety.

Key Points

Palo Alto, CA-In 1859, Florence Nightingale said, "In the surgical ward, one duty of every nurse certainly is prevention." Although Nightingale never assisted with phacoemulsification or implantation of an IOL and could not have known the signs and symptoms of toxic anterior segment syndrome (TASS), her wisdom still rings true many years later and reminds us that following the basics never loses its value, said Julie A. Burlew-Quartey, RN, CNOR, CRNO.

"Instruments that function properly and safely are essential to safe patient care," said Burlew-Quartey, clinical manager of ophthalmology at the Palo Alto Medical Foundation, Palo Alto, CA. "That's not something that we do when we have time. It really does makes a big difference in patient outcomes.

"I see this as a good opportunity for surgeons and nurses to work together and develop a respect and an understanding of each others' realities about how we take care of the patient," she continued. "When we all work together as a team, it's a fact that patients have better outcomes."

Microsurgical instruments are delicate, fragile, and, by their nature, demand special treatment. It is often difficult, however, to convince the "powers that be" at a multispecialty surgery site that unique procedures are needed for ophthalmic instruments, Burlew-Quartey said. One of the lessons learned from the 2005 TASS outbreak and the subsequent task force investigation is that specific procedures for ophthalmic surgical instruments are essential for patient safety.

Nurses are responsible for ensuring the proper care and handling of surgical instruments, according to Burlew-Quartey, and it should be a role taken seriously and performed continuously rather than whenever they have some spare time.

"This is very delicate instrumentation, and it is easily damaged," she said. "The nurse and the technician need to have the freedom to question the process and the sterility of anything at any time in a culture of no blame. That really has to be created within each operating room suite."

Start with storage

A vigilant environment starts with basics such as appropriate storage. On a small tray of cataract surgery instruments, for example, each item should be securely placed on the rubber mat, tip protectors should be in place, and, for easier sterilization, the instruments should not be crowded.

Intraoperatively, instruments should be set up in a consistent way so that anyone, including a surgeon, could reach up and instantly locate the correct item in a darkened room.

"They are delicate, so it's important that we handle each instrument separately and try not to multitask," Burlew-Quartey said. "Hand each instrument to the surgeon one at a time. It's also a good idea, working in a dark room, to have a safe zone on a back table where you put your sharps."

Other intraoperative essentials for ophthalmic instruments include keeping them free of debris and lint with a clean instrument wipe. Protective tips should be in place at all times when instruments are not in use. A procedure for passing gem blades back and forth to the surgeon also is important. Single-use items should be discarded after surgery.

OR hazards

Risks also exist in the operating room environment, she said.

"The danger elements are primarily blood, tissue, saline, sterile water, lint fibers, and dried ophthalmic viscosurgical devices," she said. "Blood and tissue, of course, are going to leave potential microorganisms on your instruments; you want to remove those as promptly as possible. Salt crystals are going to lead to damage on your instruments if not properly removed. Sterile water can cause damage to the corneal endothelium. You need to have both of these solutions on your table, but your staff needs to understand the difference between the two and when to use them appropriately."

She also recommended that the microscope be cleaned every day because it is placed over the surgical field, and that environmental surfaces should not be sprayed while instruments are in the room.

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