Orthopaedic Surgical Instrument Sets - Reducing Risks Of Musculoskeletal Disorders

  • Document Type: Guidance Note
    Keycode: web only
    Industry: Health Care Sector, 
    Category: Controlling OHS Hazards and Risks, Manual Handling, 
    Division Author: Public Sector & Community Services
    Publication Date: 06 June 2005
    Date First Published: 15 December 2004
    Summary: This guidance note provides advice on the duties of designers, manufacturers, importers and suppliers of Orthopaedic Surgical Instrument Sets with particular emphasis on packaging, transport and handling of the Instrument Sets by addressing the work organisation and practices from the designer through to the end user in the hospital.

This guidance note provides advice on the duties of designers, manufacturers, importers and suppliers of Orthopaedic Surgical Instrument Sets for use at a workplace with particular emphasis on packaging, transport and handling of the Instrument Sets by addressing the work organisation and practices from the designer through to the end user in the hospital.

It also addresses the duties imposed on employers and employees associated with the handling of Orthopaedic Surgical Instrument Sets.

Terms and phrases used in Guidance Note:

Instrument Sets:
Sets of instruments and equipment for use in surgical operations, contained in a series of trays. Sets are largest for orthopaedic surgery, such as joint replacements. Each set may contain over twenty trays.
Loan sets:
Sets of instruments which are loaned to hospitals by suppliers, transported to and from hospitals and supply warehouses.
Trays:
Usually stainless steel trays with lids, commonly around 600mm x 290mm x 150mm for orthopaedics and weighing up to 11kg.
Containers:
The trays are transported in large containers or boxes (see right) which protect the trays and instruments. A container may weigh up to 50 kg or more when packed with full trays. The trays have to be packed into and out of the containers at both the hospital and the supplier's premises.
Hazardous manual handling:
is defined in the Occupational Health and Safety (Manual Handling) Regulations 1999 ('The Regulations') as:

- manual handling having any of the following characteristics

  • repetitive or sustained application of force;
  • repetitive or sustained awkward posture;
  • repetitive or sustained movement;
  • application of high force;
  • exposure to sustained vibration


- manual handling of live persons or animals
- manual handling of unstable or unbalanced loads or loads which are difficult to grasp or hold

side opening container

Identifying the problems

  • The Regulations impose duties on an employer to ensure that any task involving hazardous manual handling is:
  • identified before any task involving manual handling is undertaken
  • before any alteration is made to objects used in a workplace or systems of work
  • before any object is used for a purpose other than for which it was designed
  • if new or additional information about hazardous manual handling associated with the task becomes available to the employer, and
  • if an occurrence of a musculoskeletal disorder is reported by or on behalf of an employee


Orthopaedic Surgical Instrument Sets, or Loan Sets, are delivered to hospitals by the instrument supplier in containers. They are then transferred to the sterilising department and prepared for use in theatres. An assessment of this manual handling task has identified the major risks arising from:

  • lifting or moving the large, bulky and sometimes heavy delivery containers, which may be crates, bins or cases;
  • pushing equipment;
  • lifting the trays in and out of containers, and on and off trolleys;
  • filling, emptying, washing, sterilising and wrapping instrument trays;
  • multiple handling of the trays during sterilisation and use in theatres, often under time pressure and with awkward postures; and
  • lifting containers on and off courier trucks when transporting containers from the supplier to the hospitals and back again.


There is a potential risk to hospital staff of musculoskeletal injury when manually handling these instrument sets in preparation for surgery. Suppliers and transport workers are potentially at risk when the sets are packaged at the point of supply and transported to hospitals.

The risk of musculoskeletal injury is due to repetitive or sustained application of force, awkward postures or movements, and the application of high force. There is also an increased risk of manual handling injury due to work environment and equipment factors; for example:

  • the inadequate size and poor design of sterilising departments, operating theatres and storage area
  • poorly designed courier vehicles
  • poorly designed handling equipment, and
  • inadequate access to hospital delivery points.


Note: Hospitals are responsible to ensure as far as is practicable that couriers are not exposed to risks whilst accessing or egressing their property and for any safety issues whilst on site.

Legal responsibilities

All employers have responsibilities under the Occupational Health and Safety Act 2004 to provide and maintain a safe and healthy workplace.

Employers also have responsibilities under the Occupational Health and Safety (Manual Handling) Regulations 1999 to identify, assess and control any risks of hazardous manual handling and ensure that the risk is eliminated or reduced as far as is reasonably practicable.

Designers, manufacturers, importers and suppliers also have duties to ensure safe design and construction of plant under both the Act and the Regulations. All have a duty to ensure that any risk of musculoskeletal disorder occurring when the plant is properly used at a workplace is eliminated or if it is not reasonably practicable to eliminate the risk, that the risk is reduced so far as is reasonably practicable. A breach of this duty is an indictable offence.

Reducing the risk by designing the process

It is important that all duty holders conduct a risk assessment of any hazards associated with manual handling tasks.

Manual handling occurs at each point from supplier to hospital theatre. By organising the process of ordering, receiving, distributing, transferring and using Loan Sets, the amount of manual handling can be minimised and the process made more efficient and cost effective. Hospitals should nominate a management representative who is responsible and accountable for co-ordinating the process described in this guidance note. There should be documented procedures available. In addition the hospital requirements should be reflected in the contracts for supply and delivery of Loan Sets.

Communication protocols
Good communication can reduce the workload and prevent handling of Loan Sets that are excess to requirements. If Loan Sets are collected and returned in time for procedures, multiple handling to and from theatre, or into and out of storage can be reduced. Regular systematic communication should be in place between suppliers and hospitals and within hospitals. This includes organising:

  • surgery workload. A communication process should exist between surgeons/medical staff, patient bookings, loan set coordinators/orthopaedic nurses and sterilising staff to ensure deliveries of Loan Sets closely match up with the needs for surgery.
  • logistics. A systematic process should exist between suppliers, couriers and hospitals regarding the status of Loan Sets, including

- coordinating delivery points and protocols (how, when and where to deliver the sets)
- establishing appropriate contacts within the hospital, and
- having suitable mechanical handling equipment available at all points of the process.

Strategic management of the loans process
By managing the number and timing of deliveries, the transfer and handling of Loan Sets can be minimised. For example, a hospital may keep a set over a week to be used on consequent days.

Alternatively, the consignment of sets to hospitals can be negotiated to avoid multiple handling and decrease turn around time pressures. For example, a hospital may retain sets which relate to specific regular surgical procedures on a semi permanent consignment system.

Container/tray identification
A consistent coding or identification system should be in place to avoid unnecessary handling of containers or trays that are surplus to requirements. Examples include:

  • digital check-in photos
  • checklists in the same order as instruments or implants
  • easy-to-interpret colour or number codes, and
  • labels with procedure/surgeon/patient details on trays.


Improving Loan Set handling

Container design
Containers used for the delivery of Loan Sets should be strong, durable, weatherproof and of as low a weight as possible. Where handles are fitted they should:

  • be cylindrical with a non-slip finish
  • have a diameter of about 20 to 40 mm
  • be at least 15 mm long, and
  • have a clearance of at least 50 mm so that the whole hand can comfortably grasp the handle.


Note: Handles should only be used to pull or slide containers, not to lift and carry.

The provision of redesigned containers from suppliers will begin across Australia during 2005. Containers with a front or side opening to allow trays to be slid in and out have been trialled and accepted by stakeholders. To aid movement, the containers should be either mobile with large wheels and brakes or able to be stacked on a trolley. The container dimensions should be:

  • approximately 600 mm wide and 300 mm deep to allow the trays to neatly fit in
  • high enough to efficiently carry sets of trays without causing a visual impediment (approximately 400 mm), and
  • big enough for the task without being able to contain very high weights.



Note: Research is currently underway to reduce the weight of the instrument trays and of the instruments. This may even further reduce manual handling risk in the loans process.

Mechanical aids
The use of mechanical aids should be considered in all stages of the Loan Set delivery and handling process; i.e. supplier, courier and hospital.

Recommended equipment includes:
Suppliers: Adjustable height trolleys or work surfaces for packing the loan set containers
Couriers: Trolleys appropriate for the weight and secure delivery of the containers. Appropriate trolley and vehicle design should include:

  • large trolley wheel size for access to lifts, and
  • a vehicle with loader or ramp for easy accessibility.


Hospitals: Handling requirements in different sections of a hospital call for different types of mechanical aids. For example:

Point of delivery.

  • Mobile trolleys should be fitted with brakes.



Sterilising Section.

  • Trolleys with adjustable height surfaces with rollers or slide surfaces for unloading should be used to match the height of benches and sterilisers to move trays by sliding rather than lifting.
  • Automatic steriliser loaders where possible.
  • Adjustable height workbenches for packing and wrapping.


Operating theatre.

Prepared trays on wheeled storage racks, ideally incorporating angled shelves for easy visual access to prosthetics, and flat shelves for instruments.

Note: All adjustable height equipment should be electrically operated, or if this is not practical, foot pedal operated. Mechanical equipment in itself should not introduce any other hazard.

correct technique



Workplace environment
The physical work environment needs to be designed to minimise manual handling risk. Good design parameters include:

  • adequate space and signage to allow for delivery, storage and sorting in an organised manner. Separation of delivery and storage areas is preferred.
  • provision of door openers, appropriate door widths, smooth floor surfaces and barriers removed.
  • layout of supply workshops and sterilising units to optimise work flow and minimise double handling; e.g. work flow from decontamination/washing to packing to sterilising.
  • storage of prepared trays on mobile racking ready to be wheeled into theatres.
  • using shelves between thigh and shoulder height to minimise lifting and reaching.


Changing work practices to reduce risks

Manual handling work practices should be assessed for risk to employees. Staff should be advised to promptly report any incidents of musculoskeletal discomfort or unsafe aspects of the work. Where such a report has been made, a risk assessment must be undertaken in accordance with the Regulations. Where practicable, such risk assessments must be undertaken in consultation with the health and safety representative of the relevant designated work group.

Correct Technique


To reduce the risk of injury when manually handling Loan Sets, the following work practices are suggested:

  • adhere to protocols for communication, delivery and processing of loan sets to minimise handling;
  • use mechanical aids, where possible, at all stages of the process where manual handling presents a hazard, particularly where loading and unloading tasks are undertaken;
  • separate contents of large trays to minimise weight. Optimally tray weights need to be restricted to around 5 kg. Scales incorporated in the bench system or a portable set on a trolley would allow trays to be weighed as part of the handling activity;
  • lift only single trays (no double trays);
  • rotate jobs and use team work to share tasks, e.g. within the sterilising area, to avoid long periods of repetitive handling and to decrease the number of trays handled per person;
  • train and supervise staff on the correct use of equipment and safe work practices;
  • check containers for broken locks, clips etc before and after supply to avoid spills or breakages; and
  • staff numbers should be adequate to meet demands.


In addition, employees should be trained in the performance of manual handling risk assessments and consulted in any provision of risk controls. If the introduction of mechanical equipment is part of a risk control strategy, staff require training and supervision in the correct use of that equipment.

Acts and Regulations

  • Occupational Health and Safety Act 2004
  • Occupational Health and Safety (Manual Handling) Regulations 1999

Acts and regulations are available from Information Victoria on 1300 366 356 or order online at www.bookshop.vic.gov.au.

View the legislation at Victorian Law Today at www.legislation.vic.gov.au.

Standards Australia

Copies of standards can be obtained by contacting Standards Australia on 1300 654 646 or by visiting the web site at www.standards.com.au.

Further information


WorkSafe Victoria
Manual Handling (Code of Practice No.25, 2000)

Copies of publications, including codes of practice, can be obtained by contacting WorkSafe Victoria on 03 9641 1333, or your local WorkSafe Victoria office.

Other useful health and safety information available at the WorkCover Victoria website at www.workcover.vic.gov.au


Other

Special Note on Codes of Practice: Codes of Practice made under the Occupational Health and Safety Act 1985 provide practical guidance to people who have duties or obligations under Victoria's OHS laws. The Occupational Health and Safety Act 2004 allows the Minister for WorkCover to make Compliance Codes which will provide greater certainty about what constitutes compliance with the OHS laws.

Codes of Practice will continue to be a practical guide for those who have OHS duties and WorkSafe will continue to regard those who comply with the topics covered in the Codes of Practice as complying with OHS laws. WorkSafe will progressively review all Codes of Practice and replace them with guidance material and in appropriate cases, with Compliance Codes.

Note: This guidance material has been prepared using the best information available to WorkSafe Victoria. Any information about legislative obligations or responsibilities included in this material is only applicable to the circumstances described in the material. You should always check the legislation referred to in this material and make your own judgement about what action you may need to take to ensure you have complied with the law. Accordingly, the Victorian WorkCover Authority extends no warranties as to the suitability of the information for your specific circumstances.