Making the Choice

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Instrument Standardization

By R. Michael Appleby

Standardizing surgical instruments used in various departments in the hospital can control costs, increase instrument processing efficiencies, and help in training personnel.

The challenge for instrument-using departments today is offering surgeons the specific instrument they need to perform a procedure, while keeping costs under control. The goal of instrument standardization is to identify one pattern of a specific instrument to be included throughout all the instrument sets being used. This facilitates the processing department's ability to replace missing or broken instruments in instrument sets, and the surgeon's comfort level when using standard instruments in different sets. It also reduces training time for processing personnel, as there are fewer specific instrument patterns to learn.

Selecting a Vendor
The first decision to make is determining which instrument vendor will be the primary vendor. National contracts might dictate which vendor you use, but when the choice is not limited, there are a number of factors to consider. A knowledgeable sales representative from a company that offers a wide variety of instrument patterns for a large number of surgical specialties can provide invaluable assistance in instrument standardization. The vendor should offer instruments in several quality tiers, so you can purchase the appropriate instrument for the intended use. Some vendors can provide a computerized software package to assist in instrument asset management and standardization.

A good computer program should offer an electronic catalog with pictures of a multitude of surgical instruments. Technicians should be able to add instruments that might not be in the catalog but are included in their instrument sets. The software also should allow technicians to build instrument set "pick lists" and print these out for inclusion with the processed sets. It is helpful in keeping track of instruments that are lost or out for repair, as well as in creating requisitions for instruments to be purchased. In addition, such a system should be able to generate a variety of reports to aid in instrument asset management. Many vendors offer such programs, although some might require purchase commitments for advanced versions or value-added features. Once a department has selected a prime vendor for its surgical instrument needs, the staff can begin to standardize the patterns for purchasing.

The Quality Decision
Surgical instruments can be standardized based on quality as well as specific patterns. Instruments used in the ER or on the floor, which might be thrown out with the trash or stolen, do not have to be of the same high quality as instruments for the operating room, labor and delivery, or outpatient surgery. There are a number of cost-effective options for areas that do not require the highest quality instruments. These include prepackaged sterile disposable instrument sets, or sets that are made up in-house, using lower quality instruments, and reprocessed after every use. Decide which is the most cost-effective choice and which provides appropriate consistency in quality and pattern for the intended use. These patterns may be standardized in the same manner as first line patterns.

Standardizing Patterns
The operating room, labor and delivery, and outpatient surgery demand superior surgical instruments. It's important to retain quality but standardize the patterns chosen. Generally, the more detailed the procedure, the more specific the instrument pattern required. There are more than 10,000 hand-held surgical instrument patterns that basically perform one of seven functions: to cut or incise, to retract, to grasp/hold/occlude, to dilate or probe, to cannulate or drain, to aspirate/inject/infuse, to suture or ligate.1 Many different patterns are available to accomplish the same task. By standardizing on basic patterns, expensive duplication costs are eliminated.

Instrument patterns that lend themselves to standardization tend to be more general in nature and are employed for soft-tissue uses in multiple instrument sets. These include: ring handle forceps and clamps, needle holders, scissors, thumb forceps, and retractors. Because these instruments usually are the high-volume patterns purchased, selecting a standard pattern can eliminate a lot of duplication of instrument inventory in the processing department. As patterns for standardization are selected, be sure to revise the instrument set pick list to reflect the choices made.

Making the Choice

Forceps and Clamps
Ring handle forceps and clamps include towel and drape forceps, sponge forceps and a multitude of hemostatic forceps. Decide which will be the standard pattern for a specific type of instrument. For example, either a Kelly or Crile could be used if there is a need for a 5" or 6" hemostat. Select one and make it the standard forceps to be used every time a procedure calls for an instrument larger than a Mosquito but smaller than a Pean. The same logic would apply in determining whether a straight or curved pattern will be used, as well as the specific instrument type.

Needle Holders
Needle holders should be selected for length and needle holding ability. Select standard patterns for 4-0 and larger, 5-0 to 6-0, and 7-0 and smaller. Surgical instrument sales representatives can recommend appropriate needle holders for each task and help eliminate multiple patterns, making it easier for the processing department to replace damaged needle holders from inventory. Standardization for specialty needle holders can be achieved by selecting lengths and needle holding requirements for those trays.

Decisions about scissors include length of standard scissors and whether or not they should be "gold handle" with inserted blades or stainless steel blades. All instrument set scissors should offer the surgeon consistency, regardless of the instrument set. A typical choice offering of 4" scissors could be iris, tenotomy, strabismus, or Metz. Decide on a standard straight and curved pattern and then use that as the basic scissors selection. Using the same suture scissors, bandage scissors, or utility scissors in all instrument sets also helps to reduce costly duplication.

Thumb Forceps
Basic thumb forceps should be selected by jaw configuration and length. Dressing forceps have serrated jaws and tissue forceps have toothed jaws. Select a standard pattern for each style in the lengths required for the instrument set. Instead of choosing 5", 5-1/5," and 6" thumb forceps, standardize on one length for short forceps. DeBakey, Cushing, and other specialty patterns can also be standardized where they are used in a majority of trays.

Standardize basic retractors as to width and length, and handheld patterns as to whether they have sharp or dull prongs. Richardson and Kelly retractors are the same basic instrument except for the size of the blade; the names are often interchanged. Select specific basic patterns for each blade size required and standardize on small, medium, and large retractors. Standardizing on retractors with replaceable blades and/or other parts can reduce the number of surplus parts needed to maintain this type of retractor in working condition.

The Instrument Board
Once you have standardized the basic soft-tissue instruments and revised instrument set pick lists, the processing department should order extra instruments for their instrument board. The processing instrument board can be a pegboard where instruments are hung by type and size; or a cabinet or drawer, where they are separated by size and type. Processing personnel will be able to replace missing or damaged instruments from the instrument board without having to take an instrument set out of service or process an incomplete set. Standard instrument patterns can be ordered in economical quantities, less often, so that the staff always has enough of the basics to keep instrument sets in service. Inventory levels should be established for each instrument and stock should be checked weekly so that orders can be placed for items below ideal level.

Specialty Sets
Specialty instrument sets can also benefit from standardization. The more a department is able to use the same instrument pattern in multiple sets, the less often mistakes occur in the composition of the sets. Instrument sets will have a more consistent feel for surgeons, regardless of the set they are using. Charge nurses and surgeons might have to be involved in the making the decision, but processing and duplicating instrument sets is much easier when fewer distinct patterns are used within a specialty service.

Benefits of Standardization
Instrument standardization can help control instrument costs by reducing the number of instrument patterns utilized within a facility, thereby increasing processing efficiencies and making it easier to train personnel. The returns realized are well worth the time and energy it takes to standardize surgical instrument patterns.

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R. Michael Appleby is an instrument asset management Consultant for Allegiance Healthcare Corporation, V. Mueller in McGaw Park, Ill. He has been associated with V. Mueller since 1969.

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