Nursing Lesson Plan 610
by Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT
President/CEO of Seavey Healthcare Consulting
Troubleshooting
Instrument Stains
Learning Objectives
1. Explain basic procedures helpful in
reviewing instrument processes in each
area of use or care
2. Review the difference between stains,
rust and pitting, and tell how color can
be used to diagnose stains
3.State recommendations for treating
stains, based upon the extent of the
problem
This series of self-study lessons on CS topics was developed by the International Association of Healthcare
Central Service Materiel Management (IAHCSMM),
and can be used toward CRCST re-certification or
toward nursing credits. Pfeidler Enterprises and
IAHCSMM both offer grading opportunities.
Earn Continuing Education Credits Online:
Nursing Credit: Pfiedler Enterprises will award nursing credit for this Self-Study Lesson Plan.
Pfiedler Enterprises is a provider approved by
the California Board of Registered Nursing, Provider
Number CEP 14944, for 1 contact hour.
Obtaining full credit for this offering depends upon
attendance, regardless of circumstances, from beginning to end. Licensees must provide their license
numbers for record keeping purposes.
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O
ne of the more challenging aspects of managing
surgical instruments involves determining the cause of stains on their
surfaces. Some people believe that instruments manufactured with
“stainless” steel will remain in a like new condition forever. Unfortunately,
that is not the case. In fact, stainless steel is not actually stainless. Staining may suggest
problems with a facility’s decontamination, assembly and sterilization processes, and/
or with instrument use in the Operating Room (OR). To address this problem, we
must first understand what causes stains. Then, the instrument’s condition must be
assessed to determine whether it can be refurbished. Stains left unattended may cause
pitting, which makes an instrument non-repairable and, ultimately, may result in the
complete breakdown of its outer surface. Central Service (CS) technicians can assist
by recognizing stains, providing tools to investigate their root cause, and suggesting
methods to reverse the problem.
Objective 1: Explain basic
procedures helpful in
reviewing instrument
processes in each area of
use or care
Investigation of staining should include
reviewing instrument processes in each
area of instrument use or care.
Review storage of new or
repaired instruments
The passivation layer on instruments
is an iron/chromium oxide layer on the
instrument’s surface. The manufacturing
process should include a step that will
begin to develop a passivation layer.
This bond becomes stronger and more
mature as instruments are handled, and
The certificate of course completion issued at the
conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of
attendance.
In order to receive credit you must go to
www.pfiedlerenterprises.com/IAHCSMM/610 and
complete the test, evaluation and registration forms.
Once completed, you will be directed to print your
certificate of completion.
Each 20 question online quiz with a passing
score of 70% or higher is worth two points (2 contact
hours) toward CRCST re-certification of 12 CEs.
IAHCSMM Credit: IAHCSMM will award credit for
this Self-Study Lesson Plan toward the renewal of a
CRCST certification.
To receive IAHCSMM credit, please visit
www.iahcsmm.org for online grading (nominal
fees will apply).
More information: For questions or problems about
Nursing Credits available for this lesson plan, please
contact [email protected].
For questions about IAHCSMM Credit available
for this lesson plan, please contact us at
312.440.0078 or [email protected].
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Nursing Lesson Plan 610
they become more stain-resistant over
time. Therefore, new instruments can
be more easily stained than their used
counterparts until the passivation layer
matures.
New instruments should be removed
from packaging immediately because
plastic wrapping may create condensation
during temperature fluctuations and
cause rust to form. New instruments must
move through a complete processing
cycle to assure they are free of any
manufacturing oils or debris. Caustic
chemicals that may cause corrosion, such
as solvents or housekeeping cleaning
supplies, should not be stored in the
immediate area because they could
release vapors and cause surface damage
to the instruments. Storage areas should
be kept clean and dry, so dust and dirt
cannot collect on instrument surfaces.
Investigate instrument
care in the OR
Assure that instruments are not soaked in
saline or other caustic agents, including
betadine (iodine solution), alcohol,
balanced salt solution (BSS; used in
eye procedures), medication, or other
chemicals that can damage instrument
surfaces during surgical procedures.
Instruments should be continuously
wiped clean of saline, tissue, blood, bodily
fluids, and/or chemicals during surgical
procedures. Chlorides are especially
corrosive to stainless steel. Exposure
to saline or tap water that may contain
chlorides or other damaging chemicals
for an extended time can severely damage
instruments.
During procedures, scrub personnel
should use a sterile surgical sponge
moistened with sterile water to remove
gross soil from instruments (a basin of
sterile water can help facilitate this). It is
important that sterile water, not saline, be
use to wipe down instruments during the
procedure.
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Instruments should not be
decontaminated in scrub or hand
sinks with tap water and hand soap. All
instruments, including those required
to be sterilized in an immediate-use
steam sterilization cycle, should be
decontaminated in an area designed for
decontamination and with a cleaning
solution recommended by the instrument
manufacturer.
Assure that instruments are
returned to the CS area immediately after use
After completion of surgical procedures,
used instruments should be transported
to the decontamination area as
soon as possible. Prior to transport,
instruments should be kept moist. This
can be accomplished by placing a towel
moistened with water (not saline) over
the instrument; placing it inside a package
designed to maintain humid conditions;
or using an instrument spray, foam or gel
designed for instrument pre-treatment.
If processing is delayed, bacterial
proliferation should be minimized
through the use of pre-cleaning
disinfectants. Soiled instruments may
remain in the Emergency Department,
Labor & Delivery, or other clinical areas
for long periods. Developing procedures
to return these instruments to the CS
area quickly will improve their care and
reduce the opportunity for instrument
stains or rust.
New instruments
should be removed
from packaging
immediately because
plastic wrapping may
create condensation
during temperature
fluctuations and cause
rust to form. New
instruments must move
through a complete
processing cycle to
assure they are free of
any manufacturing oils
or debris.
Review decontamination
procedures
Instruments must be processed quickly to
remove any tissue, blood, bodily fluids,
or caustic chemicals. Assessment in
decontamination begins with water
quality. Untreated tap water may be “hard”
or “soft,” depending on the water supply.
Local water traveling through hospital
pipes may pick up more impurities or
chemicals, including rust particles.
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nursing Lesson Plan
Water should be tested for impurities,
including silicone dioxide; heavy metals,
such as iron, cadmium and lead; as well
as chlorides and phosphates. Tests to
measure the pH (acid/alkaline levels)
of the water are also important. Note:
Instrument manufacturers recommend a
neutral pH and, as caustic chemicals and
impurities are filtered and removed, the
pH will move to a neutral level. Ideally, the
water source for the decontamination area
will be treated to remove these impurities.
At a minimum, the final rinse (manual or
mechanical) should be with treated (i.e.,
deionized, distilled or reverse osmosis)
water. Treated water is preferred for the
final rinse to help prevent staining and
contamination of instrumentation.
Detergents are also a primary concern
when assessing instrument stains. All
cleaning solutions must be measured
accurately and mixed correctly. This is
especially true if instruments are washed
manually. All visible debris must be
removed from the instruments, and
detergents must be completely rinsed,
preferably with treated water. Clean, soft
brushes should be used to clean instruments
with lumens (i.e., suctions) and complex
instruments (i.e., orthopedic implant
sets) to assure that no hidden rust or
debris remains. The device manufacturers’
written Instructions for Use (IFU) should
include recommendations for the type
and size of cleaning brushes to be used.
Box locks and joints require special
attention to remove all debris.
When ultrasonic cleaners are used,
assure that the proper chemicals, in the
correct amounts, are utilized. Always
follow the manufacturer’s written IFU
and confirm that the water is changed
according to these requirements.
Infrequently-changed water evaporates
and creates higher concentrations of
cleaning solutions, which changes the
pH level. Also, excessive contaminates
(protein) in the water can adhere to
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instrument surfaces and cause damage.
Following the ultrasonic treatment,
instruments should be rinsed thoroughly.
Foam residue generated by improperly
rinsed instruments could impede
cleaning in the washer-decontaminator.
When assessing the washerdecontaminator, consider the source and
quality of the water, which enters the
machine. A pH-neutral, low-foaming
detergent is preferred. If the detergent
is not pH-neutral, there must be a
neutralizing rinse at the end of the cycle.
Pumps must be regularly checked to
ensure that they are working properly,
and that detergents and lubricants are
being metered correctly. Equipment
and water and chemical lines must be
properly maintained. Instruments should
be positioned in the washer-disinfector
in a manner that ensures contact of
the cleaning solution with all surfaces
of the items. All jointed instruments
should be in the open or unlocked
position, with ratchets disengaged. Racks,
pins, stringers, or other specificallydesigned devices can be used to hold the
instruments in the open position.
CS technicians should consult the
device manufacturer’s written IFU to
determine the appropriate cleaning
agent(s). The agent should be compatible
with the medical device to be cleaned.
The cleaning agent should be easily
removable from the medical device by
rinsing, so that the device does not retain
residual chemicals in amounts that could
be harmful to patients, damage the device
itself, or create other hazardous situations.
The cleaning agent manufacturer’s
written IFU should also be carefully
followed. The volume of water used in the
cleaning sink or other cleaning container
(i.e., transport bin, basin, etc.) should be
calculated, and appropriate dilution rates
should be determined to ensure consistent
and accurate cleaning chemistry use. When
using an automated chemical delivery
When ultrasonic
cleaners are used,
assure that the proper
chemicals, in the
correct amounts, are
utilized. Always follow
the manufacturer’s
written IFU and confirm
that the water is
changed according to
these requirements.
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Nursing Lesson Plan 610
Figure 1: Color Indicates Causes of Stains
system/device or sink doser, calculation
of sink volume may be necessary.
Chemistry mixing should occur before
instruments are placed in the solution. It
is never appropriate to place instruments
in a sink and then add water or other
chemicals. Remember that chemicals are
concentrated, and their improper use
can result in a pH level that is far from
the recommended neutral range (around
6.8 to 7.2). The desired neutral pH is
obtained only with appropriate dilution
and thorough mixing. Highly acidic or
alkaline chemicals can damage and stain
instruments.
Review instrument
assembly procedures
Instruments should be dry when
they are removed from the washerdecontaminator because water droplets
can create spotting/stains.
CS technicians who assemble sets
should perform quality checks. In
addition to checking functionality, they
should confirm that all instruments were
disassembled during decontamination
and that they are clean. Hinged
instruments should be lubricated because
moveable parts are susceptible to friction
that may break down the surface and lead
to rust and corrosion.
Personnel should be familiar with
instrument quality and enssure that poor
quality instruments are not mixed with
those of high quality. Ions from the poor
quality metals may deposit themselves
onto stainless steel instruments and
damage their surface. Instrument
sets should be checked to ensure that
instruments with visible rust, corrosion
or pitting are removed. Rust may transfer
and “seed” onto quality instruments
during sterilization.
Linens that will come in contact with
instruments should be inert (incapable
of forming chemicals during contact
with them). If cloth wraps and/or cotton
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Brown/Orange Stains
High pH - improper soaps, bakedon blood, soaking in saline or using
laundry soap (usually is not rust)
Bluish-Black Stains
Exposure to saline, blood or
potassium chloride
Reverse plating if two types of metals
are placed in ultrasonic together
Dark Brown/Black Stains
Low pH acid stain - detergents
or dried blood
Multi-Color Stains
Excessive heat - “hot spots” in
autoclave
Light and Dark Spots
Water spots from allowing
instrument to air dry
Bluish-Gray Stains
Cold sterilization solution used outside
manufacturer guidelines
towels are laundered and then put in
instrument sets, detergents may leach
onto the instruments. Some facilities use
towels or bath blankets on sterilizer racks
to facilitate drying;, however detergents
and chemicals may be vaporized by the
steam during sterilization, and this can
affect the instruments’ surfaces.
Facilities may have unique systems to
move steam from an internal boiler to
the sterilizer; therefore, it is important
to assess steam quality to assure that it
is clean, and to confirm that the filters
between the boiler and autoclave are
in place, clean and operational, so
impurities are not carried from the pipes
into the autoclave. Excessive additives or
conditioners to the steam distribution
system can cause pack and instrument
staining and/or instrument damage.
Biomedical personnel can advise if any
chemical additives have been added to
the boiler, which may condense on the
interior of the sterilizer’s chamber and on
instruments.
Review Sterilization
Procedures
Staff members must consistently follow
the manufacturers’ IFU for routine cleaning
and maintenance of the sterilizer’s internal
walls and drains. Water and steam quality
varies from facility to facility, and the
quality may also change within the
building(s) during each season of the year.
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nursing Lesson Plan
Determine whether
instrument sets are
drying properly
Wet sets may lead to rust if instruments
remain moist for extended periods
of time.
Review sterile
instrument storage
Assure that humidity in storage areas is
within recommended levels (30-70%)
and, as with the storage of new and
repaired instruments discussed above,
confirm that no caustic chemicals are
stored in the area.
Objective 2: Review the
difference between stains,
rust and pitting, and tell
how color can be used to
diagnose stains
Understanding the difference between
stains, rust and pitting can help to
diagnose instrument issues.
A stain is a discoloration on an
instrument’s surface.Rust is a red or
orange coloration on the surface of
surgical instruments resulting from
oxidation. Note: Ensure that a “stain”
observed is not dried blood.
Pitting is erosion (corrosion) of an
instrument’s outer surface, which renders
it beyond repair. It may range from tiny
visible small dots to large deep holes.
Use the eraser test to check for rust by
rubbing an eraser over the stain/rust. If
the spot is easily removed, it is a simple
stain. If you discover pitting under the
stain, it cannot be repaired, and the
instrument should be removed from
service. Pitting indicates that the rust is
generated from the pit and not from an
external source. Even though cleaned, the
pit will continue to generate rust, which
will “seed.”
To test for rust or stains resulting
from the sterilization process, place a
white sheet across the sterilizer rack,
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and process the load in the normal
manner. Then, determine if the towel/
sheet contains stains or debris. If either is
present, it is most likely coming from the
steam lines and/or chamber walls.
Objective 3: State
recommendations for
treating stains, based upon
the extent of the problem
Recommendations for treating stains
depend upon the extent of the problem.
If a small percentage of instruments is
stained, on-site cleaning with a nonabrasive cleaner, a commercial stain
remover or an eraser may be sufficient
to remove the stain. If more than
approximately 5% and less than 30%
of the instruments are stained, there
is likely to be a significant problem,
which requires thorough investigation
and resolution with a broader plan
for instrument maintenance. For
example, sending affected instruments
for full refurbishment, including bead
blasting, inspection and replacement
of those, which are not repairable,
may be appropriate. When more than
approximately 30% of instruments
are stained, a full investigation of
the causative factor(s) and a repair/
refurbishment program is required.
If the staining has gone on for an
extended time, it is very likely that some
instruments will show pitting that makes
them non-repairable.
instruments remain in good working
order for many years.
References
• Association for the Advancement of
Medical Instrumentation. ANSI/AAMI ST79.
Comprehensive Guide to Steam Sterilization
and Sterility Assurance in Healthcare
Facilities. ANSI/AAMI ST79:2010 & A1:2010
& A2:2011 & A3:2012 & A4:2013.
• Association of periOperative Registered
Nurses. 2015. Recommended Practices
for Cleaning and Care of Surgical Instruments.
Guidelines for Perioperative Practice.
• Arbeitskreis Instrumenten-Aufbereitung
(Instrument Preparation Working Group).
2004. Proper Maintenance of Instruments.
8th Edition.
• International Association of Healthcare Central
Service Material Management. 2007. Central
Service Technical Manual. 7th Edition.
• Schultz R. 2005. Inspecting Surgical
Instruments: An Illustrated Guide.
In Conclusion
Serious detective work is required to
successfully address instrument stains.
Each step in the instrument handling
process, including the methods of
managing the instruments in each
location, should be reviewed. Purchasing
quality instruments, managing them
with appropriate processes, following
manufacturers’ IFU, and maintaining
sterilizers and washers should assure that
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