Handle With Care
Delicate Instruments Require Proper Reprocessing Technique
By John Roark
Replacing even one surgical instrument in a set can cost hundreds of dollars. Juggling the rising cost of instrumentation with shrinking budgets and heat from the operating room (OR), the value of a pro-active care and repair program is worth its weight in gold.
The most important thing to focus on is why we take care of the instruments, says Richard Schule, BS, CST, CRCST, CHMMC, FEL, manager of the surgical processing department at the Cleveland Clinic. We do a lot of educating, and yet from time to time well see someone carrying a tray of instruments by the handle on its side like a suitcase, and the contents flop over. Its like, what was the point of all of that? Or when they finish the procedure, theyre breaking down the back tables and they put the heavy instruments on top of the delicate items to come down into reprocessing. I think youre always a cheerleader to promote good care and handling techniques. Its a never-ending process continual reeducation and hammering that into the forefront of the mind.
New instruments should be visually inspected upon purchase and inserviced prior to use. If you are a person who knows the instrument, you want to look at it, make sure that its in good working order. Make sure its sharp if its a cutting instrument, or that it retracts if it should, says Rose Seavey, RN, MBA, CNOR, ACSP, immediate past president of the American Society for Healthcare Central Service Professionals (ASHCSP) and director of the sterile processing department at The Childrens Hospital in Denver. I also make sure that any new instruments go through the washer before they get used.
If its a complicated instrument like a da Vinci surgical robotic arm, you really want to go through all of its working elements and make sure that it does work. Or if its a drill or power instrument, put it through all of its motions and make sure that it works before you wrap it and sterilize it.
We make sure that all of the pieces are there, and that the instrument actually functions as its supposed to, says Carla McDermott, RN, technical advisor for the International Association of Healthcare Central Service Material Management (IAHCSMM). Some of these instruments sit in a warehouse for awhile. Weve received some that were rusty right from the start, and we ship those right back. If we werent given the opportunity to inspect them, wed never be able to prove that we didnt damage them. You just need to make sure that its a usable instrument and that theres no damage to it, and that youve got all the pieces.
If its a new instrument or product, you need to be sure that you have the sterilization and flash instructions for that product, and to do the education with the staff, continues McDermott. If youve got a new widget, youd better be telling everyone what it is and where it belongs, or youll never see it again. That includes the OR staff as well. There has to be an education component whenever you get new toys.
Becki Harter, CST, RCST, CRCST, FEL, president and CEO of Sterilization By Design, tackles instrumentation cost on four fronts: care and handling, packaging, instrument repair rotation and par levels.
Theyre all important, says Harter. You have to have all of those components to make it work. If you dont have good care and handling, your repair bills are going to be high. You cant have a great repair/refurb program but have thousands of instruments on your shelf that you dont need. You cant have a good par level, and then go to a repair/refurb company thats not original equipment manufacturer (OEM) certified. Youve got to address it from all angles.
Care and Handling
One word sums up the solution to care and handling: education. Inservice training should be set up to address the following:
- How to handle general and specialty instrumentation
- Cleaning instructions
- Sterilization practices
- The importance of consistent high-level attention to care and handling practices, and developing protocols that are strictly adhered to
- McDermott also underscores the need for staff education. Once a year is not enough, she says. Every time you buy something new, everyone has to know what it is, how it works, how to take care of it.
Harter recommends that managers and associates in central processing departments make a quarterly review of problem areas in care and handling. Training that is focused on problem areas should be developed, implemented and maintained, and attended by all central processing and clinical associates.
Difficulties can arise when trying to assess the processing needs of an instrument, says Harter, who recommends asking the following questions when devising a plan of action for the care and handling of instruments:
- Are there removable parts?
- Is the instrument sensitive to current disinfection/cleaning practices?
- Can the instrument be processed through mechanical cleaning/disinfection devices?
- What are the sterilization parameters of the instrument?
- Are the sterilization parameters able to be met?
The answers to these questions play an integral part in the increase or decrease of the costs required to maintain the integrity of an instrument.
Seavey stresses the need for consistency when packaging. Always do it the same way, she says. Get into the routine and learn the best way to protect the instruments. When you pack them in a container, be very careful. Not only when youre putting the sets together, but when theyre coming downstairs. We have a great working relationship with the OR, but if a set comes down and it does not come down protected if youve got mallets and other heavy instruments on top of the delicate instruments we will call up to the OR and ask them down, or we take a picture of it if we can, and send it up and say, Look how this was treated. We keep a digital and an instamatic camera in the department at all times.
Every storage/sterilization management system (SSMS) should be carefully evaluated before purchase. Factors to keep in mind are:
- Does the SSMS meet the care and handling needs of the instrumentation it will hold, or does it create an environment for damage?
- Is it sensitive to the utilization of space in an operating room instrument storage area?
- An SSMS should not create additional storage space problems, it should not be too heavy, causing potential hazards to associates lifting or moving it.
- The SSMS should offer reconfiguring capabilities to accommodate different types of instrumentation.
- The SSMS should accommodate modifications by means of silicone inserts, pin mats, posts or pins. The customer needs to be in control of the SSMS inner capabilities, says Harter. Time taken to make the right choice will prevent the expense of the wrong choice.
- The SSMS should meet all processing/regulatory requirements such as weight, drainage, protection and Federal regulatory requirements.
Instrument Repair Rotation
Pro-active, preventive maintenance should be aggressively monitored, and can cut down on the frustration resulting from compromised instruments making their way into the OR, says Seavey. Frustration all the way around of the doctors, nurses, the techs when they get screamed at because somethings not working,. The surgical case goes better because the doctor always has a good working tool, and theres more reliability and it results in a better working communication.
We have a spreadsheet. All of our trays are labeled with numbered, stainless steel tags, says McDermott. We know which number tray went out last. On the spread sheet I have all the different trays, and I have them set up on a schedule. Some of them are refurbished more often that others it depends on how often that tray gets used. Weve got basic major and minor trays that are used 15 times a day, every day, and I have neurosurgery trays that get used twice a month. I have adjusted on that spreadsheet when they are due, based on usage. Of course, if somebody complains about something on a tray, we take care of that immediately.
Monitoring rotation can be done low tech especially if youve got a person who deals with sending out your repairs all the time, says Seavey. Maybe your instrument supervisor deals with the same person who comes in and theyve got a routine where they go through a list and check things off. You can do it this way, but its not as reliable as the technology of an instrument tracking system. We do a variety of both.
Instrument tracking systems facilitate the monitoring of instrumentation tracking through the use of bar codes. A rotation schedule can be set up through software which will generate reports tracking monthly repairs, or set up an annual schedule ensuring that instruments are touched multiple times once a quarter, twice a year, whatever the customer dictates.
McDermott looks forward to implementing a bar coding system into her facility. Its going to make a lot of things more efficient, she says. Because of all the VCJD business going on, were going to be challenged to track these instruments to the patient. At present, thats not a possibility. Even if I had to only track my neurosurgery instruments and drills, I would be hard pressed to do that manually. The bar coding will make that much more efficient and reliable.
It will also provide the paper trail that I need to say, This tray is being reprocessed, its being flashed inappropriately because I dont have enough instruments. You need to buy two more cut-down trays, or two more pacemaker trays, because its inappropriate to be flashing these things. These are routine instruments.
Problematic items become routine items because youve set it up into the system when youre going to send instruments out on a regular basis, says Schule, endorsing bar code tracking systems. When your customer, the end user the surgeon in this case starts to complain that theres a problem, we can tell them well up the sharpening schedule. Well rotate set A out for set B, and you wont have a problem.
If an instrument is on a regular rotation for inspection, the nature and cost of any refurbishment or repair is significantly less over time, says Harter. As the instrument is consistently maintained, the need for major repairs decreases, decreasing the overall cost.
Maintaining par level prevents instrument sets from being out of service while an instrument is being repaired, helps identify high usage or loss of instruments enabling management teams to address problem areas either by increasing inventories or by identifying the cause of loss, and developing a plan of action to prevent that loss. Par level also clarifies and itemizes instrumentation expenditures.
I go into hospitals and I see thousands of instruments that they dont use, says Harter. Its crazy to have those on the shelf. I know of a couple of companies that buy and sell instruments for third world countries. I tell the hospitals: lets sell to them, see if they have anything you need trade for that, or buy something that you can use with those instruments rather than let them sit on the shelves collecting dust. Youre refurbishing them once a year for what? If three months later its got dust on it, thats telling you something: you dont need it. My point is if you havent seen it, if you dont even remember what it is, you dont need that instrument. I understand that it takes time to get that scaled down, but its very well worth the effort. At the hospital where I currently work, they dont have any more than five of anything anywhere.
It took me three and a half years to get them to that point, though. A lot of training, a lot of swapping, they had to work hard. There are a lot of hospitals that have stuff that theyve never seen, used, or know the cost of.
Harter recommends the following steps to effectively monitor par level:
- Record instrumentation usage for one or two months.
- Make a list of the high-usage instruments and how many are used in a month.
- Create a pegboard or drawer system to organize the par-leveled instruments.
- Label desired system with instrument name, company name, and order number.
- Begin ordering the high-usage instruments on a month-to-month basis, keeping to your assigned par level.
When shopping for an instrument repair company, look for consistency, thorough knowledge and legitimate references.
Weve been with the same company and had the same repair person for more than 20 years, says Seavey. I look for consistency, trustworthiness I dont want somebody to come in here and do additional repairs that I dont need. I want somebody that will come in and work side by side with my staff, and that my staff knows. They should have a good reputation I dont want a fly-by-night company thats only been around for a couple of years. I want somebody who has a solid knowledge base I really want to see their credentials, what kind of training that they actually have did they just learn it in a garage? If I was going to switch companies, I would certainly want to call many of their customers and get some feedback. Not just any references, but references of people I know.
Harter advises: let the buyer beware. There are some companies out there who have literally gone to their own garages to do the work, and theyve destroyed thousands of dollars worth of instruments, either by diminishing their life or by destroying them, and calling it the hospitals fault, she says. There are one or two companies out there that are sharpening things every time they put their hands on them. Theyre doing it every week. Youre doing something that is supposed to prolong the life, but by doing it too much youre actually shortening it. There is such a thing as over-refurb, and I think that people should be cautious about that.
Harter also cautions against companies that charge for instrument evaluation in addition to any repair work done. Thats crazy. The customer should only be charged for the actual work done, not for just looking at the instruments. There are companies out there refurbishing just for the sake of refurbishing when the instrument may not need it. You have people charging as much as $5 or $10 per instrument just to look at it. The average instrument set has 100 instruments in it. Somebodys making some money. Somebodys losing some, too.
There are companies out there that dont charge you for the evaluation of the instrumentation. In fact, theyll do a routine cleaning and make them look nice, and they wont charge you for that unless they actually have to do something to repair a box lock or sharpen it. Those are the companies that you need to keep.
Mobile repair companies offer the convenience of on-site repair, resulting in quicker turnaround.
Flexibility is the main thing with my customers, says Schule. Ive got surgeons who at the drop of a dime want something done. I look at flexibility, quality and the education of the individual performing the service. And then finally comes cost. Thats the difference depending on what hat youre wearing. Some people look at cost first; Im not a proponent of that.
Integrated Medical Systems (IMS)
Instrument Service & Repair
Scope Exchange, Inc.
Spectrum Surgical Instruments
Surgical Operational Services Inc.
Total Repair Express
Richard Wolf Medical Instruments
Third Party Reprocessors
Tri-State Hospital Supply Corp.
Vanguard Medical Concepts