"Processing of Procedure Trays"
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Many healthcare facilities (HCFs) assemble and produce procedure trays for patient care.

What is a procedure tray? A tray used to perform a specific procedure on a patient. Examples of procedure trays include tracheotomy tray, cut down tray, paracentesis tray, etc. Procedure trays should be specific to the procedure being performed however they can be multi-purpose (i.e. All-Purpose Tray) to keep the inventory of trays low. These trays bring all the instruments and supplies needed for the physician to perform the procedure, in many instances without the assistance of a nurse or aide.

Preparation and Assembly:

When procedure trays are set-up, they should be simple in design. Very often procedure tray contents are developed and there is no review of the tray contents thereafter. Sometimes when reviewing tray lists it is determined that the procedure is no longer performed, or a disposable tray is currently being used in place of the reusable tray. As with any process, procedure tray contents should be periodically reviewed for accuracy and relevance to patient care.

When assembling a procedure tray the instruments should be inspected for cleanliness, functionality and that all parts are present. The contents for the tray can be a group of items necessary to perform a specific procedure or they can be a group of items that will be used as part of a larger procedure such as a set-up pack. The end result is that the tray should be designed to reduce the time patient care providers spend gathering supplies and instruments for specific procedures.

Usually the tray is set up on a flat metal tray called a "Mayo" tray. Today there are also autoclaveable plastic trays that can be used for this purpose. A reusable, delinted surgical towel should be placed on the metal tray before placing instruments and other items. The towel creates a space between the metal instruments and the metal tray and enhances drying at the end of the sterilization cycle.

The basic components of procedure trays include, at a minimum: items for skin preparation; Items for draping; supplies to give local anesthetic; items for surgical closure

Skin preparation items would include 2"x2" or 4"x4" non-sterile gauze sponges or 6" cotton-tipped applicators that can be used to prepare the skin with an antiseptic solution. Usually the gauze are picked up by a sponge stick and used to "paint" the antiseptic on the skin. The gauge sponges should not be placed inside inside of the jaws of the sponge stick and the jaws clamped closed. This could prevent steam from reaching the jaws of the instrument. Instead, the gauze should be placed flat on the tray. The area where the procedure is being performed needs to be draped; usually surgical towels are used (they are clamped together with towel clips) or specialty drapes can be included such as circumcism drapes.

Drapes can be reusable (must be laundered between use, be lint free and without holes or defects) or single use. Single use drapes must be non-sterile and autoclaveable since the majority of procedure trays are processed in pre-vacuum steam sterilization cycles. The single use drape manufacturer should provide sterilization instructions to the facility.

The patient is given a local anesthetic before the procedure begins to lessen the discomfort. In order to administer the local anesthetic, the doctor will usually need a 5cc syringe and various size and gauge needles. Many facilities still use glass syringes for procedure trays. Glass syringes require manual cleaning and careful handling to prevent chips and cracks. When inspecting glass syringes make sure the barrel fits snugly into the syringe. One way to determine if the barrell fits correctly is to invert the syringe and if the barrell slides out then the barrell is not the right fit. Any glass syringe that is damaged or does not fit correctly should be replaced. If disposable syringes are used, these are provided to the facility single wrapped, sterile. The facility must check with the syringe manufacturer regarding placement of the syringes on a tray that will be steam sterilized. Remember, the manufacturer has already sterilized the syringes and in most cases the manufacturer will not recommend re-sterilization. The use of sterile, single use needles is common practice today. The needle manufacturer must also be contacted to provide information regarding placement of the sterile needles on a tray to be steam sterilized. All lumened devices (needles, catheters) should be flushed with distilled water immediately prior to sterilization.

Medications should not be included on special procedure trays unless the drug manufacturer has provided written instructions for sterilization, re-sterilization and any adverse effects to the medication from the sterilization process.

Items for skin closure usually includes sutures. The suture is placed on the outside of the tray and usually contained inside a dust cover. If multiple sutures are required, they are sometimes placed in a small plastic bag for containment and then placed inside the dust cover. It is important to review the suture needs routinely to prevent unused suture material from accumulating on Nursing Units.

Tray consistency is critical. Every tray that is produced in the Sterile Processing Department should be accurate and consistently prepared. We expect this from a tray prepared by an outside vendor; our customers (doctors and patients) deserve the same from an in-house prepared tray. To help ensure that all trays are prepared the same way reference materials should be available for the SPD staff. The reference materials can be file cards, count sheets and/or photos with the tray set-up. Reference materials should be specific (i.e. 3 each curved mosquitos); list items in the order as they should appear on the tray; and contain general information such as the tray name, number of trays, etc. In addition, the reference material should answer these questions: How are the items cleaned? Sterilized? What items get added to the tray after sterilization? What material is used to wrap the tray? Where does the tray go after sterilization? Whatever reference system is used, it is important to make sure that the tray contents and set-up of the tray are reviewed periodically for accuracy. When the procedure trays' contents are being reviewed, Nursing personnel and the physicians performing the specific procedures should be included in the review process.

Procedure Tray
Procedure Tray

Placement of items on the tray should follow the order of use of the items and are usually assembled left to right. Therefore, the items to prepare the skin should appear on the left side of the tray followed by the local anesthetic items (needles/syringes), drapes and towel clips, items to perform the procedure (including knife handle and blade), clamps, scissors and needle holders. If reusable knife handles are used, the blade, in the foil package, is placed on the tray near the knife handle. The foil packet should not be opened. Steam cannot penetrate the foil packet but will sterilize the outside of the packet for handling by the doctor. If a disposable knife blade/handle is used, check with the manufacturer to see if the handle/blade can be placed on the tray for sterilization. Some manufacturer's of disposable knife handles/blades do permit steam sterilization of pre-sterilized handles/blades. Sometimes a "paint cup" is required to hold the betadine or skin antiseptic. Any medicine glasses or paint cups should be facing upright. Any items that are nested (smaller bowl inside a larger bowl) need to be wicked (separated by an absorbent material). Instruments should be placed on a stringer; can be strung on the sponge stick or the surgical towel used to line the tray can be folded at the bottom to create a pocket. The instruments can be held open by placing one handle inside the fold and one outside the fold. In any event, all instruments should be held open for sterilization. Any reusable needles or items with lumens (i.e. red rubber catheters) should be flushed with distilled water immediately before steam sterilization. If multi-part devices are required, make sure all parts are present.

All SPD employees should be trained in processing of procedure trays. The training should include inspection of all instruments, needles, inspection of reusable items for deterioration, what the tray is used for, how it is ordered and charged, etc.

It is recommended to number multiple alike procedure trays and identify the par levels within the SPD Department. This will help reduce instances of non-availability. For example, tracheotomy trays are usually required post-operatively for Thyroidectomy patients in the event of neck swelling. The SPD Department should never be without Tracheotomy Trays. SPD personnel should be trained to scan the procedure tray shelves daily to ensure the par levels are maintained at all times.

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