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for a maximum number of uses based on the number of times the instruments have been energized on the robot. Each robotic instrument can cost between $600 and $4,000. These expensive devices must be handled thoughtfully in the surgical suite and in the sterile processing department in order to protect the facility’s investment and maximize the number of procedures per instrument.
Processing challenges of robotic instruments As with other surgical instrumentation, the goal of reprocessing is to remove all debris and bioburden from the instru- ments so that sterilization of all surfaces can occur. Any failure to sterilize can lead to potential cross-contamination and infec- tions. Removing all bioburden and soils is also important because residual soils can lead to instrument damage and malfunc- tions, which can cause patient injuries and/or surgical delays.
Robotic instruments, which have com-
plex designs and mechanics, pose unique cleaning challenges that may increase the risk of residual soil. For example, many devices have multiple articulation points controlled by various wires and pully systems that become contaminated during a procedure. Technicians are challenged to clean around the wires and within the channels in which they lie. Not only is it difficult to reach these points, but techni- cians are unable to see all areas clearly. Another unique robotic challenge is char. Char occurs when bioburden on the instru- ment is exposed to a cauterization arc that burns the bioburden onto the instrument surface and creates a baked-on soil that is especially hard to clean.
Failure to remove bioburden or char in these tight, complex segments of a robotic tool can block sterilant from reaching these areas and impede sterilization. It can also lead to the formation of biofilm, an aggre- gate of bacteria and soils in a sticky matrix that adheres to surfaces and becomes very difficult to remove.
In decontamination
The special instructions continue as the instruments move to the decontamination area. Cleaning involves multiple steps and equipment. For example, the Da Vinci Endowrist instruments from Intuitive Surgical require 15 steps for decontami- nation alone. Reprocessing a single set of robotic instruments according to their instructions can take three hours or more to complete. Decontamination technicians may be tempted to skip steps or shorten soak times as the pressure to turn robotic sets increases. Unfortunately, shortcuts can potentially create opportunities for residual soils and biofilm formation.
Challenges of usage counts Figure 1:
Robotic grasper showing bioburden in articulation channel and wire guides.
The most restrictive challenge of these instruments is their limited reuse. Each instrument has a defined number of times that it can be used and sterilized. Contin- ued reuse beyond the prescribed process- ing limits may lead to instrument failure or the formation of biofilm, both of which have the potential to injure patients. Robotic instruments typically have a manual means to track uses. Technicians manually advance the sterilization count during processing typically by marking the instrument. However, misunderstand- ings about who does the advancing and when it should occur can lead to problems. Missing a count leads to inadvertent over- processing and overuse. On the other hand, extra counts lead to premature
SELF-STUDY SERIES
In the OR To assure thorough cleaning of robotic instruments, every step of their instruc- tions for use must be followed, starting with point-of-use treatment. Operating room staff must remove debris on these instruments between uses and ensure that the device is ready for reuse during the procedure. This can be challenging when robotic instruments remain secured to the robot arms instead of being placed on a surgical stand between uses.
Post-procedure point-of-use processes typically include some disassembly and treatment to maintain moisture on the devices. However, unlike traditional surgical instrumentation, robotic instru- ments require the priming of channels and other additional steps. Remembering which devices require these extra steps can be challenging for OR staff. Missing a step can be detrimental because bio- burden can dry on surfaces and become hard to remove.
device disposal and increased cost to the facility.
Addressing the challenges Robotic instrument reprocessing chal- lenges are not going away, but they can be managed. For example, point-of-use treatment has a big impact on the success of cleaning, so OR staff should be trained and tested on all the required steps and competencies to ensure consistency among all staff members who handle the robotic devices. Consider using placards or cue cards in the OR to remind staff of the proper steps to follow for each instrument. It’s also helpful to include all necessary materials and equipment for point-of-use treatment on each case cart. This may include ushing solution, syringes, adapt- ers and point-of-use treatment products, for example. It can be especially helpful to use tubes that contain cleaning detergents or enzymes on instrument tips. These products perform two functions; they keep the soiled instruments moist, and they begin to loosen bioburden and char from the device.
Figure 2: Enzymatic cleaner within tip tubes begin to breakdown bioburden as shown by the red color in the solution
Precleaning is especially important in the case of robotic instruments since each is limited to a specific number of reprocess- ing cycles. If residual soil is found after a sterilization cycle, one reuse is wasted because the soiled instrument must now undergo an extra cleaning/sterilization cycle.
As with OR staff, training must be pro- vided for decontamination technicians,
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hpnonline.com • HEALTHCARE PURCHASING NEWS • November 2020 49
Self-Study Test Answers: 1. B, 2. A, 3. C, 4. C, 5. B, 6. C, 7. A, 8. C, 9. B, 10. A
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