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The Complex and Indispensable Requirements for Instrument Reprocessing

Article

By Tim Brooks

One of the most common questions related to the sterile processing department (SPD) is this little gem, asked by surgeons, nurses and scrub techs: why does it take so long to get our sets up to the operating room (OR)? The demand for faster turn-around of surgical instruments is constantly hampered by a number of time-related challenges. In addition, when processes are fragmented and the instrument management process is less than ideal, turnaround time can also increase.

Instrument set management is not much different from disposable sterile supply management when it comes to setting par or stock levels; demand determines inventory levels for both processes. However, surgical instrument reprocessing functions include production and handling expenses that are not incurred with disposable sterile supplies. And instrument inventory expense for hospitals can grow into millions of dollars and offer little depreciation value (compared to fixed capital assets), which can result in the belief that "less is better."

What does this have to do with time? It’s an extremely complex question that must be answered by discussing the multiple factors that impact surgical instrument turnaround.

Diversity, Complexity and Multiple Stakeholders

Today’s central service (CS) departments deal with more diverse instrumentation and more advanced sterile processing equipment than in years past. More importantly, the surgeons, who are the primary users of these instruments, generally do not understand the challenges to proper instrument handling that exist and the role the surgical staff plays in the complete reprocessing cycle. As a result, there’s a gap between what CS professionals know and what the surgeons, operating room nurses and scrub techs know.

CS professionals, the ultimate experts on instrument reprocessing, need to educate themselves and then teach their customers about the many factors that can affect instrument turnaround. CS leaders may also need to make formal presentations to hospital leadership and to the health system’s risk management, safety, and infection control departments.

Stakeholders also need to understand the impact of functions such as surgical case scheduling, preference card management, capital budgeting, and operating budgets. In addition, issues such as overbooking instrumentation, high add-on case percentages, too-low instrument set inventories, and the lack of a centralized instrument management program may be impacting turnaround times.

Time Factors

There are two types of time factors affecting instrument management; direct and indirect. Direct factors are those over which the sterile processing department has control. Once they are audited and evaluated for improvement, these factors can be optimized. Indirect factors are under the control of others and require CS staff to work collaboratively with these other stakeholders to effect improvements.

Each of the elements affects turnaround time in some way, and none should be ignored when evaluating overall time associated with instrument management. Evaluating these two lists of factors (see accompanying checklist) as they apply to a specific facility can help the sterile processing department better explain the "why" and build a case for improvement.

Instrument Inventory: How Much is Enough?

Here’s the bottom line: the length of time that surgical instruments remain in the reprocessing cycle is in great part determined by how many instruments you have and who is managing them. The first steps toward improving turnover time are: having enough instruments to start with; and then centralizing instrument management to assure efficient, timely, and high quality reprocessing.

Surgical set inventories and individual set lists differ from hospital to hospital, even though we all do the same types of procedures. Although some surgical practices may be more specialized, we are all more similar than you think. In spite of the similarities, however, there is no global benchmark or magic number for how much surgical instrument inventory to maintain. Even instrument suppliers and sterilizer manufacturers can’t provide a figure for the ideal number of sets to support our daily schedules. However, once that number is determined, some sterilizer manufacturers can provide an optimal throughput ratio of washers, sterilizers and staff to product volume.

Consultants have made some headway in assisting with inventory assessment, but they have often been limited by contract terms and an overarching mandate to reduce expenses and staff. In many cases once the consultants leave the hospital there is a tendency to revert to previous habits. It is truly up to us individually to gain the knowledge and direct the changes that can best support our facilities.

How much is enough can only be answered by studying the needs of the daily schedule and understanding how many sets are needed to respond to demand on a specific day of surgery. It’s important to note here that on any given day a typical CS department will support all surgical service lines, not just one. Turnaround time for any one service line is slowed down by the total number of cases in a day, any add-on-cases that occur, and the day’s case mix. If, for example, you have a heavy orthopedic day with additional loaner trays to process, and have added urology and heart procedures, you may end up processing instruments on a first-come-first-served basis. A schedule with a lot of daily add-on and trauma cases causes additional instrument inventory demands. Typically, surgeons do not know what is scheduled in other service lines, nor do they realize the effect that their own add-ons and special requests have on instrument demands in their own service line.

In addition, there’s the challenge of individual surgeon preferences, which dictate instrument set lists. This can lead to a decrease in standard service line instrument set inventories. Having many surgeons requesting their own preferences reduces the department’s ability to evaluate supporting set level volumes in a given service line. This generally is due to having only one or two trays for a given surgeon that are being flash sterilized to support his or her case turnover. If there are also high numbers of add-on cases, the number of trays being flash-sterilized has a tendency to go up even more. Surgeons who are allowed to bring in their own instrument sets (also used at other hospitals) create additional usage confusion.

Managing Complex Inventories

Perioperative and CS managers must strive for optimal service line inventories for instruments, supplies, and equipment. Effective manage-ment of these three inventories supports the surgeon and the service, whether it’s orthopedics, plastics, urology, cardiovascular, gynecology or general surgery. Two of these inventories, instrument sets and surgical equipment, must also be managed to meet the time constraints of scheduling and case turnover.

To add more complication, instrument inventories are typically divided into service lines that include back-up peel-pouched instruments. In addition, each instrument service line has requirements for additional handling, methods of sterilization and quality assurance. For instance, the urology inventory for cystoscopy instruments and scopes can require all four methods of sterilization – steam, EO, peracetic acid and gas plasma – and can present a number of cycle time challenges. And if flexible scopes are being used, they require even more different processing methods and quality assurance processes.

And let us not forget that change is just as constant in healthcare as in any other industry. Hospitals and surgical procedures change and advance over time. So, the instrument set inventory must evolve with current demands. It cannot rely on the capital budget process to address immediate needs for inventory changes due to such things as new services, new procedures or new surgeons. For this reason, instrument purchases are best handled by using operating budget dollars with additional contingency capital for new service lines under the management of experienced individuals within the CS department who understand process and production management.

To understand the sheer numbers a CS department deals with, here is an example: a hospital completing 10,000 surgeries annually can easily support 650 different set types with more than 1000 instrument sets, including orthopedic loaner sets containing 35,000 individual instruments with a value of more than $5 million or more. The instrument set inventory supports well over 3000 different instrument types. This same hospital’s reusable instrument inventory is subject to sterile processing, inspection and repairs, with an operating cost that can easily exceed $500,000.00 annually. In the course of a year this same hospital will sterilize 50,000 instrument sets handling more than 1.5 million single instruments!

As this example illustrates, the responsibility for managing surgical instruments and the facilities, systems and people to reprocess them is enormous, and very complex. Installing new assistive technologies such as instrument tracking systems can provide managers with excellent support for data and instrument management; some systems can even provide tracking down to the individual patient on whom each repro-cessed instrument is used. Tracking systems also provide assistive tools for the CS staff such as checklists and guidance on proper set assembly along with single instrument and set pictures.

Where Cleaning Begins

Disinfection time is divided into two categories; variable time associated with manual processes, and fixed times associated with automated mechanical cleaning. The variable manual process time is dependent on how much gross contamination is left on the instrument post-use and how many instruments/devices require manual cleaning. The amount of cleaning time increases when the OR staff does not separate instruments, clean from dirty and by set. Mixing up dirty instrument sets in the OR increases the time needed for sorting and reassembly in decontamination, and can also result in delays and mistakes.

Time is also extended when OR staff does not remove gross contamination immediately after use in the OR. It cannot be stressed enough; the longer instruments sit with gross bioburden on them, the longer the manual cleaning time will be and the greater the chance of additional through-put delays. The longer the bio-burden remains on an instrument, the faster the instrument’s passivated layer breaks down eventually requiring repairs and refurbishing. For these reasons, the most efficient manual cleaning process starts in the OR immediately after the instru-ment’s use, initiated by the OR scrub techs.

Another complicating factor is ‘the need for speed,’ which is common in surgical suites. A focus on fast room turnover can result in instrument losses, the overuse of flash sterilization, and damage to instruments. The practice of rushing case turnovers should be carefully evaluated to ensure that patient safety isn’t compromised, and that careless handling of surgical instruments doesn’t result in additional repair and replacement costs.

Outpatient surgery centers can speed their turnover because they typically have less total service line inventory and supporting equipment. However, hospitals performing instrument-intensive orthopedic total-joint cases, for example, should reconsider the wisdom of a 15-minute turnover time. A practical alternative is the practice of flip-flopping rooms, a scheduling technique used at some facilities, which allows the additional room cleaning and instrument management time needed to support safe practices. Scheduling staff, equipment, and instruments is much more efficient in a flip-flop environment.

Another counterproductive practice is holding back instruments such as cameras and scopes in the operating rooms, which only increases reprocessing time. Removing instruments from the rooms as soon as possible improves reprocessing efficiency allowing for faster turnover.

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