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Instrument Re-processing & Product Questionnaire

Cataract surgical center contact:
Name of center:
Contact person:
Telephone number:
E-mail:
Fax number:
Address:
Instrument Re-processing Questionnaire

TASS Case Information
Number of TASS cases out of total number of Surgeries performed:
1) number of cases:
2) total number of surgeries preformed:
Timeframe of TASS cases:
from to
Number of surgeons with TASS cases:
Total number of surgeons operating:


1. How many operating rooms do you use on days of cataract surgery?

2. How many cases of cataract surgery do you perform on an average day?

3. Have you observed a pattern to your cases of TASS (surgical case of day, surgery day of week, OR number)?     


4. How many trays of cataract surgical equipment do you have?

5. Do you have a written protocol which specifies the time, duration, detergents, enzymatics, type of water (tap vs sterile) and rinsing for cleaning the following re-used equipment:
Phaco handpiece         
Volume of water used to flush handpiece:
Phaco tubing         
I/A tips         
inserter         
Other cannulated equipment         
Forceps for loading IOL         
Have you had occluded I/A tips?     

6. Is any of your re-used equipment cleansed with enzymatic detergents?       

7. Is any of your re-used equipment cleansed or rinsed in an ultrasonic bath?
     

9. What type of final rinse water is used for your re-used equipment?
        

10. Is this final rinse water purchased or prepared at your facility?
        

11. Is re-used cataract surgical equipment separated from non-ophthalmologic surgical equipment through all steps of cleaning before sterilization?
      

12. Which method is used for sterilizing your re-used equipment:







13. If you sterilize your equipment with an autoclave, please indicate all that apply:
Regular inspection & cleaning documented       
Recent operational problems       
Steam produced by facility-wide boiler       
Steam produced only for autoclave       
 
Additional comments

Product Questionnaire
Please indicate below the products and procedures which were used during surgeries that were followed by cases of TASS.

Preoperative topical mydriatic 1:








Other:


Preoperative topical mydriatic 2:








Other:


Preoperative topical NSAID:








Other:


Preoperative topical skin/lid cleaning agent







Other:


Preoperative topical anti-septic:


Other:


Preoperative topical antibiotic (w/o concentration):





Other:


Preoperative topical anesthetic (w/o concentration):









Other:


Intracameral anesthetic:



Other:


Intracameral anesthetic preservative free:




Retrobulbar or peribulbar anesthetic block:




Fexible iris retractor:




Intraocular miotic (circle one):


(trade name)


Viscoelastic #1 (choose one):









(trade name)


Viscoelastic #2 (choose one):










(trade name)


BSS (500cc) intraocular irrigant (choose one):





(trade name)


Topical (15cc) irrigant (choose one):





(trade name)


Epinephrine added to BSS:




Intraocular antibiotic #1 added to BSS:



Other:



Intraocular antibiotic #2 added to BSS:



Other:


Intracameral antibiotic #1:






Other:


Intracameral antibiotic #2:






Other:


Incision (circle one):


Suture of incision:




Type of Blade/Knife (choose one):





Blade/Knife Brand (choose one):








Phaco delivery system (choose one):








Phaco tip reused:




Phaco tubing reused:




I/A tip reused:




Inserter tip reused:




Inserter reused:




Cartridge for loading IOL to Inserter:







Other cannulated equipment reused:




Custom Pack (circle one):








IOL Type (circle one):







IOL Manufacturer:







Capsule staining (select one):






Post-operative topical antibiotic:









Other:


Post-operative topical steroid:








Other:


Post-operative topical NSAID:









Other:

Additional comments
© 2008 ASCRS · 4000 Legato Rd., Ste. 700 · Fairfax, VA 22033 · (703) 591-2220