Unfortunately, there appear to be no specific standards at this time, but rather a baseline upon which a perioperative team can research and build its own protocols. Insulated electrosurgical instruments must be monitored, but to what extent? Is visual inspection, including a microscopic inspection, adequate? Or, is the use of a commercial integrity checker more effective? At what point in the instrument-use cycle should the checks be performed? From an operational standpoint, the primary goal of monitoring the integrity of electrosurgical endoscopic instruments is to establish a process in the most cost-effective manner. With this in mind, several issues can be outlined:
- The type of insulation checks to be performed
- If a commercial integrity checker is used, the criteria for choosing this checker
- The training and compliance of insulation checks
- When to perform the insulation checks
- The thickness or durability of the insulation.
Insulation checks can range from visual inspection, mechanical inspection, intraoperative monitoring or a combination of all. It certainly can be argued that visual inspection alone is inadequate because it is subjective and a pinpoint hole easily could go undetected, and instrument manufacturers recommend visual inspections. However, if an instrument company recommends a specific integrity check, then it must include it in the instructions for use on care and handling. Therefore, depending on the instrument vendor, reliance on a specific recommendation beyond visual inspection is unlikely.
Perhaps a more realistic approach would be to elicit specific recommendations from an instrument refurbishment company because its expertise lies in this area.
Because of the ambiguity, a facility should take measures to use some type of mechanical check or intraoperative monitoring. The most widespread would be the continuity tester. Issues may arise, though, on the different types available. Some may be effective in detecting a breach in insulation integrity, but also may contribute to a defect based on the amount of current that runs through the instrument during testing and the durability of the insulation.
Operator issues should be kept in mind when researching continuity testers. A facility may have the equipment available, but are all the steps being performed for adequate checks?
For example, a unit may require all four quadrants to be checked on the shaft, requiring the shaft to be passed through the tester four times.
A final approach would be to examine the use of intraoperative monitoring. Some vendors provide continual monitoring during surgery.
If a stray electrosurgical current is noted in the system, the generator will shut down. The use of this type of system requires exclusive use of that vendor’s instrumentation.
A final issue is determining when an instrument should be checked and who should check it. You also should try to identify at what point an instrument is more likely to have the insulation breached during use and processing.
This is key to determining the point or points of checking. At the same time, complying with checking procedures is essential. Adding an intraoperative check will result in an added cost for the sterile probe, but isn’t necessarily the most optimal point for checking. Maintaining insulated endoscopes is possible by establishing specific protocols within an institution.
Examine your practices and look at resources within the industry to assist with this challenge.
Cathy Hiatt, R.N., is a project administrator, perioperative services, for the University of Utah Healthcare, Salt Lake City.
This article first appeared in the October 2007 issue of Materials Management in Health Care.
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