Sponsored by:

Troubleshooting Instrument Stains

LEARNING OBJECTIVES:

CIS 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.

One of the more challenging aspects of managing surgical instruments involves

determining the cause of stains on their surfaces. Some people believe that instruments

CIS Self-Study
manufactured with “stainless” steel will remain in a “like new” condition forever.
Unfortunately, that is not the case. Staining may suggest problems with a hospital’s
decontamination, assembly, and sterilization processes, and/or with instrument use
Lesson Plan in the Operating Room (OR). To address this problem, CIS technicians must first
understand what causes stains. Then they must assess the instrument’s condition to
(Instrument Continuing Education-ICE) determine whether it can be refurbished. Stains left unattended may cause pitting
CRCST which makes an instrument non-repairable and ultimately may result in the complete
Lesson Author breakdown of its outer surface and contribute to breakage. CIS technicians can assist
Peggy Pittenger, by recognizing stains, providing tools to investigate their root cause, and suggesting
Senior Nurse Consultant methods to reverse the problem.
Instrument Management Systems
Aesculap
Center Valley, PA Your investigation of staining should include Investigate instrument care in the operating
reviewing instrument processes in each area of rooms. Assure that instruments are not
instrument use or care. soaked in saline or other caustic agents
including betadine (iodine solution), alcohol,
Review storage of new or repaired instruments.
balanced salt solution (BSS; used in eye
New instruments can be more easily stained
Instrument Continuing Education (ICE) lessons procedures), medication, or other chemicals
than their used counterparts until the passive
provide members with ongoing education in the that can damage instrument surfaces during
complex and ever-changing area of surgical instru- layer becomes more mature. The passive
surgical procedures. Instruments should be
ment care and handling. These lessons are designed layer is an iron/chromium oxide layer on the
continuously wiped clean of saline, tissue,
for CIS technicians, but can be of value to any CRCST instrument’s surface, and the manufacturing
technician who works with surgical instrumentation. blood, bodily fluids, or chemicals during
process should include a step that will begin
surgical procedures. Chlorides are especially
You can use these lessons as an in-service with to develop it. This bond becomes stronger and
corrosive to stainless steel, and exposure
your staff, or visit www.iahcsmm.org for online more mature as instruments are handled, and
grading at a nominal fee: $5 per lesson, or
to saline or tap water that may contain
they become more stain resistant over time.
bundled packages of 6 lessons for $25 (save $5) chlorides or other damaging chemicals for an
or 12 lessons for $50 (save $10). New instruments should be removed from extended time can be very damaging.
Each lesson plan graded online with a passing score
packaging immediately because plastic
Operating Room staff should not “wash”
of 70% or higher is worth one point (contact hour). wrapping may create condensation during
instruments in a scrub sink with tap water
You can use these points toward either your re- temperature fluctuations and cause rust to
and hand soap and then flash sterilize
certification of CRCST (12 points) or CIS (6 points). form. New instruments must move through
them. Assure that instruments are returned
Mailed submissions to IAHCSMM will not be a complete processing cycle to assure
to the Central Service area immediately
graded and will not be granted a point value they are free of any manufacturing oils or
after use. Remember that soiled instruments
(paper/pencil grading of the ICE Lesson Plans debris. Caustic chemicals that may cause
is not available through IAHCSMM or Purdue may remain in the Emergency and Labor
corrosion such as solvents or housekeeping
University; IAHCSMM accepts only online & Delivery Departments or other areas for
cleaning supplies should not be stored in the
subscriptions). long periods of time. Developing procedures
immediate area because they could release
to return these instruments to the Central
vapors and cause surface damage to the
Service area quickly will improve their care
instruments. Also, storage areas should be
and reduce the opportunity for instrument
kept clean and dry so dust and dirt cannot
stains or rust.
collect on instrument surfaces.
 IAHCSMM
CIS Self-Study Lesson Plan

Review decontamination procedures. Instruments instruments could impede cleaning in the stainless steel instruments and damage their
must be processed quickly to remove any washer-decontaminator. surface. Instrument sets should be checked
tissue, blood, bodily fluids, or caustic chemicals. to assure that instruments with visible rust,
When assessing the washer-decontaminator,
Assessment in decontamination begins with corrosion, or pitting are removed. Rust may
consider the source and quality of the water
water quality. Untreated tap water may be “hard” transfer and “seed” onto quality instruments
which enters it. A pH neutral low foaming
or “soft” depending on the water supply. Local during sterilization.
detergent is preferred. If the detergent is not
water traveling through hospital pipes may pick
pH neutral there must be a neutralizing rinse at Linens which will contact instruments should
up more impurities or chemicals including rust
the end of the cycle. Pumps must be regularly be inert (incapable of forming chemicals
particles. Water should be tested for impurities
checked to assure that they are working during contact with them). If cloth wraps and/
including silicone dioxide, heavy metals such
properly and that detergents and lubricants or cotton towels are laundered and then put
as iron, cadmium and lead as well as chlorides
are being metered correctly. Equipment and in instrument sets, detergents may leach onto
and phosphates. Tests to measure the pH (acid/
water and chemical lines must be properly the instruments. Note that some hospitals use
alkaline levels) of the water are also important.
maintained, and instruments must be placed towels or bath blankets on sterilizer racks to
Note: instrument manufacturers recommend
in the washer-decontaminator completely facilitate drying. Detergents and chemicals may
a neutral pH and, as caustic chemicals and
open and properly positioned to enable water be vaporized by the steam during sterilization,
impurities are filtered and removed, the pH
to reach all surfaces. and this can affect the instruments’ surfaces.
will move to a neutral level. Ideally, the water
source for the decontamination area will be de- Water, detergents, and enzymatics can all be Review Sterilization Procedures. Assure that staff
ionized or treated to remove these impurities. considered chemicals. They must be measured members consistently follow the manufacturer’s
At the minimum the final rinse should be with and mixed according to directions. This step recommendations for routine cleaning and
de-ionized water. should occur before instruments are placed maintenance of the sterilizer’s internal walls
in the solution. It is never appropriate to place and drains. Water and steam quality varies from
Detergents are also a primary concern when
instruments in a sink and then add water or hospital-to-hospital, and the quality may also
assessing instrument stains, and they must
other chemicals. Remember that chemicals change within the facility each season of the
be measured accurately and mixed correctly
are concentrated, and their improper use year. Facilities may have unique systems to move
if instruments are hand washed. All visible
can result in a pH level that is far from the steam from an internal boiler to the autoclave.
debris must be removed from the instruments,
recommended neutral range (around 6.8 Therefore, it is important to assess steam quality
and detergents must be completely rinsed,
to 7.2). The desired neutral pH is obtained to assure that it is “clean,” and to confirm that
preferably with de-ionized water. The
only with appropriate dilution and thorough the filters between the boiler and autoclave are
appropriate clean, soft brushes should be
mixing. Highly acidic or alkaline chemicals can in place, clean, and operational so impurities are
used to clean instruments with lumens
damage and stain instruments. not carried from the pipes into the autoclave.
(example: suctions) and complex instruments
Biomedical personnel can advise if any chemical
(example: orthopedic implant sets) to assure Review instrument assembly procedures.
additives have been added to the boiler which
that no hidden rust or debris remains. Box Instruments should be dry when they are removed
may be condensing on the interior of the
locks and joints require special attention to from the washer-decontaminator because water
sterilizer’s chamber and on instruments.
remove all debris. droplets can create spotting/stains.
Determine whether instrument sets are drying
When ultrasonic cleaners are used, assure that CIS technicians who assemble sets should
properly during the cool down period. Wet
the proper chemicals in the correct amounts perform quality checks. In addition to
sets may lead to rust if instruments remain
are utilized. Always follow the manufacturer’s checking functionality, they should confirm
moist for extended periods of time.
operating instructions, and confirm that that all instruments were disassembled during
the water is changed according to these decontamination and that they are clean. Review sterile instrument storage. Assure
requirements. Water changed infrequently Hinged instruments should be lubricated that humidity in storage areas is within
evaporates and creates higher concentrations because moveable parts are susceptible to recommended levels (30% - 70%) and, like
of cleaning solutions which change the pH friction that may break down the surface and the storage of new and repaired instruments
level. Also, excessive contaminates (protein) lead to rust and corrosion. discussed above, confirm that no caustic
in the water can adhere to instrument chemicals are stored in the area.
Be familiar with instrument quality and assure
surfaces and cause damage. Rinse instruments
that poor quality instruments are not mixed
thoroughly after the ultrasonic treatment.
with those of high quality. Ions from the poor
Foam residue generated by improperly rinsed
quality metals will deposit themselves onto
 IAHCSMM
CIS Self-Study Lesson Plan
Figure 1: Color Indicates Causes of Stains
Stain Color Cause Comments
Reddish brown or multi-colored deposits Residue from blood, protein, or drugs These are corrosive agents containing chloride ions. Without
proper cleaning, these residues/stains may lead to pitting and
corrosion.
Milky white to gray Lime Excessive lime in the cleaning or final rinse. This will not gener-
ally create corrosion, but it is a cosmetic concern.
Yellow-brown to blue-violet Silicates or Copper Silicates may leak from the de-ionizer or reverse osmosis treat-
ments. Residues from cleaning agents may contain silicates if
not completely rinsed. Copper may be present in steam lines or
rinse water. These conditions should not lead to corrosion.
Gray-Black Chromium Dioxide This will not generally lead to corrosion, but it is a cosmetic
concern.

More About Stains Recommendations for treating stains depend References

upon the extent of the problem. If a small ANSI/AAMI ST79. Comprehensive Guide to
CIS technicians understand the difference
percentage of instruments are stained, on-site Steam Sterilization and Sterility Assurance in
between stains, rust, and pitting:
cleaning with a non-abrasive cleaner or an Healthcare Facilities. 2006.
• A stain is a discoloration on an instrument’s eraser to remove the stain may be sufficient.
Arbeitskreis Instrumenten-Aufbereitung
surface. If more than approximately five percent and
[Instrument Preparation Working Group].
less than thirty percent of the instruments are
• Rust is a red or orange coloration on the Proper Maintenance of Instruments. 8th
stained, there is likely to be a significant problem
surface of surgical instruments resulting Edition. 2004.
which requires thorough investigation and
from oxidation. Note: assure that a “stain” International Association of Healthcare Central
resolution with a broader plan for instrument
you observe is not dried blood. Service Material Management. Central Service
maintenance. For example, sending affected
• Pitting is erosion (corrosion) of an instruments for full refurbishment including Technical Manual. 7th Edition. Chicago, IL.
instrument’s outer surface which renders it bead blasting, inspection, and replacement 2007.
beyond repair. It may range from tiny visible of those which are not repairable may be Rick Schultz. Inspecting Surgical Instruments:
small dots to large deep holes. appropriate. When more than approximately An Illustrated Guide. 2005.
thirty percent of instruments are stained, a full
Use the eraser test to check for rust by rubbing
investigation of the causative factor(s) and a
an eraser over the stain/rust. If the spot is easily CIS Self-Study Lesson Plans
repair/refurbishment program is required. If the
removed, it is a simple stain. If you discover
staining has gone on for an extended time, it
pitting under the stain, it cannot be repaired, and Lesson Author
is very likely that some instruments will show
the instrument should be removed from service. Peggy Pittenger,
pitting that makes them non-repairable.
The pitting indicates that the rust is generated Senior Nurse Consultant
from the pit and not from an external source. In Conclusion Instrument Management Systems
Even though cleaned, the pit will continue to Aesculap
Serious detective work is required to successfully
generate rust which will “seed.”
address instrument stains. CIS technicians must Technical Editor
To test for rust or stains resulting from the review each step in the instrument handling Carla McDermott, RN, ACE
sterilization process, place a white bath towel process including the methods of managing Education Specialist
or white sheet across the sterilizer rack, and the instruments in each location. Purchasing Morton Plant Mease Healthcare
process the load in the normal manner. Then quality instruments and then managing them Dunedin, FL.
determine if the towel/sheet contains stains or with appropriate processes should assure that
Series Writer/Editor
debris. If either is present, it is coming from the instruments remain in good working order for
many years. Jack D. Ninemeier, Ph.D.
steam lines and/or chamber walls.
Michigan State University
Figure One explains how color can be used to East Lansing, MI.
diagnose stains.
 CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
CIS Troubleshooting Instrument Stains
Questions (circle correct answer):

1. Quality surgical instruments made of 7. Ideally de-ionized water should be 12. Erasing stains or rust from an
stainless steel will never stain or rust. used in the decontamination area. instrument’s surface will help to
CRCST At the minimum, de-ionized water determine whether the stain or rust
True
should be used for the final rinse. is coming from an external source or
False from the instrument itself.
True
True
2. Operating room personnel can soak False
instruments in saline or tap water False
because CIS technicians will quickly use 8. To assess instrument staining concerns
correct processing procedures to address during decontamination, CIS technicians 13. Reviewing the cause of instrument
the problems this practice creates. must investigate which of the following? stains requires investigating everywhere
the instrument travels and everything
True a. Water quality
that touches it.
False b. Water quality and equipment function
True
c. Water quality, equipment function,
3. New instruments are guaranteed to False
and detergent usage
be clean, sterilized, and ready to place
d. Water quality, equipment function,
in sets. 14. When instrument sets come from the
detergent usage, and how instruments
washer-decontaminator wet and then
True are positioned in the washer-
sit on wire racks, stains may develop as
False decontaminator.
the water droplets dry.
True
4. Mixing multiple grades of surgical 9. Detergents used for instrument
instruments in sets is an acceptable decontamination but not those used False
practice because all instruments require to launder towels which are part of
the same basic processing protocols. instrument sets are a consideration 15. Stains on instruments which occur
when assessing instrument stains. during sterilization may result from:
True
True a. Failure to clean and maintain the
False
False sterilizer’s inner walls and drains

5. Instruments must be processed quickly b. Poor steam quality

after use to remove any tissue, blood, 10. Water used in steam sterilizer boilers
c. Dirty or missing filters in the steam line
bodily fluids, or caustic chemicals which may carry unwanted chemicals and
rust that will seed on the instruments. d. All the above
may lead to staining or rust.
True True

False False

6. Instruments used in clinics, emergency 11. While checking and lubricating surgical Sponsored by:
departments, and other locations instrument box locks is important
should be returned to the central because their proper operation helps
processing area in a timely manner to the surgeon, this practice has no impact
minimize the potential damage caused on instrument stains.
by blood or bodily fluids which may True
remain on them.
False
True
False
REQUEST FOR PAPER/PENCIL SCORING (please print or type information below)
REQUEST FOR ONLINE SCORING (payment and scoring made directly online at www.iahcsmm.org using either online check or credit card)

q I have enclosed the scoring fee of $15. (Please make checks

payable to Purdue University. We regret that no refunds can be Name
given.)
Mailing Address (Be sure to include apartment numbers or post office boxes)
q Check here if you have a change of address

q Check here if you wish to have your results emailed to you City State Zip code
( )
Detach quiz, fold, and return to:
Daytime telephone IAHCSMM Membership Number
Purdue University
PEC Business Office
Stewart Center, Room 110 • 128 Memorial Mall Email Address
West Lafayette, IN 47907-2034 If your name has changed in the last 12 months, please provide your former name
(800) 830-0269 Purdue University is an equal access/equal opportunity institution