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Troubleshooting Instrument Stains
CIS
CIS Self-Study
Lesson Plan
(Instrument Continuing Education-ICE)
CRCST
Lesson Author
Peggy Pittenger,
Senior Nurse Consultant
Instrument Management Systems
Aesculap
Center Valley, PA
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in the
complex and ever-changing area of surgical instru-
ment care and handling. These lessons are designed
for CIS technicians, but can be of value to any CRCST
technician who works with surgical instrumentation.
You can use these lessons as an in-service with
your staff, or visit www.iahcsmm.org for online
grading at a nominal fee: $5 per lesson, or
bundled packages of 6 lessons for $25 (save $5)
or 12 lessons for $50 (save $10).
Each lesson plan graded online with a passing score
of 70% or higher is worth one point (contact hour).
You can use these points toward either your re-
certification of CRCST (12 points) or CIS (6 points).
Mailed submissions to IAHCSMM will not be
graded and will not be granted a point value
(paper/pencil grading of the ICE Lesson Plans
is not available through IAHCSMM or Purdue
University; IAHCSMM accepts only online
subscriptions).
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.
One 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. Staining may suggest problems with a hospital’s
decontamination, assembly, and sterilization processes, and/or with instrument use
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
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 and contribute to breakage. CIS technicians can assist
by recognizing stains, providing tools to investigate their root cause, and suggesting
methods to reverse the problem.
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
procedures), medication, or other chemicals
than their used counterparts until the passive
that can damage instrument surfaces during
layer becomes more mature. The passive
surgical procedures. Instruments should be
layer is an iron/chromium oxide layer on the
continuously wiped clean of saline, tissue,
instrument’s surface, and the manufacturing
blood, bodily fluids, or chemicals during
process should include a step that will begin
surgical procedures. Chlorides are especially
to develop it. This bond becomes stronger and
corrosive to stainless steel, and exposure
more mature as instruments are handled, and
to saline or tap water that may contain
they become more stain resistant over time.
chlorides or other damaging chemicals for an
New instruments should be removed from extended time can be very damaging.
packaging immediately because plastic
Operating Room staff should not “wash”
wrapping may create condensation during
instruments in a scrub sink with tap water
temperature fluctuations and cause rust to
and hand soap and then flash sterilize
form. New instruments must move through
them. Assure that instruments are returned
a complete processing cycle to assure
to the Central Service area immediately
they are free of any manufacturing oils or
after use. Remember that soiled instruments
debris. Caustic chemicals that may cause
may remain in the Emergency and Labor
corrosion such as solvents or housekeeping
& Delivery Departments or other areas for
cleaning supplies should not be stored in the
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.

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. 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 de-
ionized or treated to remove these impurities.
At the minimum the final rinse should be with
de-ionized water.
Detergents are also a primary concern when
assessing instrument stains, and they must
be measured accurately and mixed correctly
if instruments are hand washed. All visible
debris must be removed from the instruments,
and detergents must be completely rinsed,
preferably with de-ionized water. The
appropriate clean, soft brushes should be
used to clean instruments with lumens
(example: suctions) and complex instruments
(example: orthopedic implant sets) to assure
that no hidden rust or debris remains. 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
operating instructions, and confirm that
the water is changed according to these
requirements. Water changed infrequently
evaporates and creates higher concentrations
of cleaning solutions which change the pH
level. Also, excessive contaminates (protein)
in the water can adhere to instrument
surfaces and cause damage. Rinse instruments
thoroughly after the ultrasonic treatment.
Foam residue generated by improperly rinsed
IAHCSMM
CIS Self-Study Lesson Plan
instruments could impede cleaning in the
washer-decontaminator.
When assessing the washer-decontaminator,
consider the source and quality of the water
which enters it. 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 assure that they are working
properly and that detergents and lubricants
are being metered correctly. Equipment and
water and chemical lines must be properly
maintained, and instruments must be placed
in the washer-decontaminator completely
open and properly positioned to enable water
to reach all surfaces.
Water, detergents, and enzymatics can all be
considered chemicals. They must be measured
and mixed according to directions. This step
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 washer-decontaminator because water
droplets can create spotting/stains.
CIS 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.
Be familiar with instrument quality and assure
that poor quality instruments are not mixed
with those of high quality. Ions from the poor
quality metals will deposit themselves onto
stainless steel instruments and damage their
surface. Instrument sets should be checked
to assure that instruments with visible rust,
corrosion, or pitting are removed. Rust may
transfer and “seed” onto quality instruments
during sterilization.
Linens which will contact instruments should
be inert (incapable of forming chemicals
during contact with them). If cloth wraps and/
or cotton towels are laundered and then put
in instrument sets, detergents may leach onto
the instruments. Note that some hospitals use
towels or bath blankets on sterilizer racks to
facilitate drying. Detergents and chemicals may
be vaporized by the steam during sterilization,
and this can affect the instruments’ surfaces.
Review Sterilization Procedures. Assure that staff
members consistently follow the manufacturer’s
recommendations for routine cleaning and
maintenance of the sterilizer’s internal walls
and drains. Water and steam quality varies from
hospital-to-hospital, and the quality may also
change within the facility each season of the
year. Facilities may have unique systems to move
steam from an internal boiler to the autoclave.
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.
Biomedical personnel can advise if any chemical
additives have been added to the boiler which
may be condensing on the interior of the
sterilizer’s chamber and on instruments.
Determine whether instrument sets are drying
properly during the cool down period. 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, like
the storage of new and repaired instruments
discussed above, confirm that no caustic
chemicals are stored in the area.

CIS Self-Study Lesson Plan
Figure 1: Color Indicates Causes of Stains
Stain Color Cause
Reddish brown or multi-colored deposits Residue from blood, protein, or drugs
Milky white to gray Lime
Yellow-brown to blue-violet Silicates or Copper
Gray-Black Chromium Dioxide
More About Stains
CIS technicians understand the difference
between stains, rust, and pitting:
• 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: assure that a “stain”
you observe 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.
The 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 bath towel
or white sheet across the sterilizer rack, and
process the load in the normal manner. Then
determine if the towel/sheet contains stains or
debris. If either is present, it is coming from the
steam lines and/or chamber walls.
Figure One explains how color can be used to
diagnose stains.
IAHCSMM
Comments
These are corrosive agents containing chloride ions. Without
proper cleaning, these residues/stains may lead to pitting and
corrosion.
Excessive lime in the cleaning or final rinse. This will not gener-
ally create corrosion, but it is a cosmetic concern.
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.
This will not generally lead to corrosion, but it is a cosmetic
concern.
Recommendations for treating stains depend References
upon the extent of the problem. If a small ANSI/AAMI ST79. Comprehensive Guide to
percentage of instruments are stained, on-site Steam Sterilization and Sterility Assurance in
cleaning with a non-abrasive cleaner or an Healthcare Facilities. 2006.
eraser to remove the stain may be sufficient.
Arbeitskreis Instrumenten-Aufbereitung
If more than approximately five percent and
[Instrument Preparation Working Group].
less than thirty percent of the instruments are
Proper Maintenance of Instruments. 8th
stained, there is likely to be a significant problem
Edition. 2004.
which requires thorough investigation and
International Association of Healthcare Central
resolution with a broader plan for instrument
Service Material Management. Central Service
maintenance. For example, sending affected
instruments for full refurbishment including Technical Manual. 7th Edition. Chicago, IL.
bead blasting, inspection, and replacement 2007.
of those which are not repairable may be Rick Schultz. Inspecting Surgical Instruments:
appropriate. When more than approximately An Illustrated Guide. 2005.
thirty percent of instruments are stained, a full
investigation of the causative factor(s) and a
CIS Self-Study Lesson Plans
repair/refurbishment program is required. If the
staining has gone on for an extended time, it
Lesson Author
is very likely that some instruments will show
Peggy Pittenger,
pitting that makes them non-repairable.
Senior Nurse Consultant
In Conclusion Instrument Management Systems
Aesculap
Serious detective work is required to successfully
address instrument stains. CIS technicians must Technical Editor
review each step in the instrument handling Carla McDermott, RN, ACE
process including the methods of managing Education Specialist
the instruments in each location. Purchasing Morton Plant Mease Healthcare
quality instruments and then managing them Dunedin, FL.
with appropriate processes should assure that
Series Writer/Editor
instruments remain in good working order for
many years. Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI.
 CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
CIS Troubleshooting Instrument Stains
Questions (circle correct answer):

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

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

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