Infection Control Today - 07/2002: Instrumental Knowledge

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Ask and You Just Might Receive
"Basic set" in one hospital may be "customized" in another. It just depends on where you are and what you are doing

By Michelle Gardner

Depending on the type of surgery being done, the number of instruments in a set can cover the basics of the procedure to being prepared for anything with multiple instrument sets comprising several sizes of devices.

"Some doctors have specialties, like orthopedics and urology, and they have instruments for the type surgery they are doing," says Bonnie Ohlrogge, instrument coordinator for The Children's Hospital of Denver (TCH). "Ortho doctors want things like mallets, while urologists might want small needle holders because they are suturing tiny areas."

In the case of TCH, an average major set would include a knife handle, forceps, mosquito and Kelly clamps and various scissors. "The service leader designates the instrument set, but we try to make it as consistent as possible and have them use the same instruments for the same procedures no matter who the doctor is," explains Ohlrogge. "It helps with inventory when we don't have to buy special items."

Predictably, most of the cases at the Denver facility are children, but the hospital has treated adult patients. "We have a lot of different instruments depending on the size of the patient," says Ohlrogge. "We figure patients 6 years old and younger require one size of instruments and those older than 6 years have another set. If the case is only done once or twice a year, doctors may bring items from their hospitals. For instance, dentists do procedures while the child is under anesthesia so it is less traumatic."

Sales representatives may offer a doctor the use of their specialized sets, which allows them to avoid extra inventory and only pay for what they use. "Service leaders talk to the doctors and order necessities for a procedure," says Ohlrogge. "If the doctor needs plates that we don't carry, the sales rep will bring them in. The items go through decontamination and we give them back to the rep. It is kind of a renting system."

But Sometimes, You Can't Have It All

It is common to have customized instrument sets at University of Iowa Healthcare in Iowa City. "We have lots of customized sets here, so I am not sure if they qualify as customized any more," says Mike Murphy, manager of central sterilizing services. "Our computer system can compare two different sets and tell us what is different, and we can enter a set name and the system will tell us the differences in the sets."

Murphy does point out that a hospital's location may dictate how things are done. "I live in a small town, but we have a huge medical center," he says. "We get physicians who come here to practice and the medical center allows them [to ask for specific instruments]. I think the market dictates some of the customization."

Just like instrument sets depend on the type of surgery being performed, every physician is trained differently. "If you get a physician from Michigan and another from California, they have been trained two different ways with different systems," says Murphy. "They use different instruments to complete the same process, doing it equally well. They use different things in different parts of the country."

While medical institutions would like to give doctors an opportunity to use different instruments, they are restricted by inventory and budget. "We only have two hip systems out of five or six (that are available), but we can't afford to have them all," shares Murphy. "If a physician goes from here to Michigan, he or she may have a completely different hip set."

Similar to TCH in Denver, University of Iowa Healthcare standardizes its basic sets. "They are assembled ahead of time so when a physician tells us what they would like [to use] we try to put it together," says Murphy. "It is possible we can give them an existing set. Plus, using the computer program, we can tell what instruments are in a set, then add individual instruments [to complete the requested set]. On any given procedure they are using only 40 percent of the instruments, but in the course of all the procedures, they may use 100 percent of the instruments."

It can be a difficult task to distribute instruments among sets that get surgeons through a day, yet not waste instruments in trays. Even custom sets may have surgeons asking to add two or three items. You can easily end up with more instrument sets that must be tracked and increase inventory costs considerably.

Orthopedics poses the greatest dilemma because there are so many bones and sizes. "When you get into implants, screws and systems, there is no way to predict usage or what is commonly used," says Murphy. "You can't do away with ortho systems. If you need to replace a hip, you need the hardware removal stuff from the old system to get the hardware out. To keep it all in stock and up to date is the hard part."

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