By Timothy P. Brooks, BS, CSPM
With the new landscape of managed care, it is vital for hospitals and medical centers to enhance their efficiencies. With the modernization of computer software systems designed for healthcare, there is an opportunity for improvements. The Conflict Schedule Checker (CSC) is available in most OR scheduling systems. Healthcare organizations may or may not be aware of this capability and its functionality to surgical instrument management.
Conflicts are something that we all deal with in the course of a day. Conflicts do not differ from hospital-to-hospital and are pretty much the same regardless of where you may work. Staffing conflicts, supplies, equipment, along with instrumentation conflicts, challenges the OR and sterile processing departments (SPDs) every day. Conflicts add up when the daily schedule exceeds what can be sterilized and rarely receives follow-up to address the root-cause.
Challenges faced by facilities can include:
- Surgeons with little understanding of scheduling conflicts and are more focused on delays that may disrupt their current surgical procedure and room turnover for the follow-on cases.
- The OR focus on room turnover typically receives more attention along with surgeon coming late to the case, both of which can result in delays.
- Instrument set conflicts cause delays when overbooking of resources is allowed, which in turn costs operating dollars.
Most OR scheduling systems have CSC built into the program used to book procedures and manage preference cards. Oddly enough, many hospitals do no use the conflict instrument check function in their scheduling system to its fullest potential, if at all. For the most part, only specific or unique OR tables or one-of-a-kind pieces of equipment are identified as a scheduling conflict; some may tie in rooms or staff, but most do not include surgical instrument sets.
Typically, RN resource coordinators managing the daily schedule are the only people who know that a single piece of equipment cannot be booked in two rooms at the same time and make scheduling adjustments without hesitation to eliminate the conflict. It becomes so routine that it does little to fix the root cause and masks the conflict. However, when the primary RN resource coordinator is not there, the person stepping in must try to run the schedule the best they can with limited knowledge of the equipment inventory. If conflicts are not built into the scheduling system, the scheduling office simply adds on procedures, thus over-booking equipment with no knowledge of the resulting chaos. They are also overbooking instrument sets that will affect the entire schedule for any given day.
Any piece of equipment or instrument set needed in a surgical procedure is subject to over-booking. Too many operating rooms simply make schedule changes in place of using the system. This results in the room and equipment shuffle to make everything fit into what we have rather, than what makes sense. Surgeons hear too often that their procedure will have to be moved, on the day of surgery, due to some form of overbooking of equipment. Worse yet, they see the pending delay turn into late starts and long days. Most, if not all, of the case-shifting and delays can be resolved long before the day of surgery when the operating room CSC is used as designed.
Surgical instrumentation rarely, if ever, receives scheduling conflicts, yet overbooking leads to immediate-use steam sterilization and high levels of fast turnover set recycles. Instruments are then subject to low-level quality assurance and high turnover resulting in shortened wash cycles or worse yet, hand-washing between patients. This process eliminates the high-level disinfection phase of cleaning increasing the potential for residual bioburden remaining on surgical instruments, putting both staff members and patients at risk.
When set inventories do not support demand and the there is no CSC in place, short-cuts become the norm. Automated wash cycles and sterilizer dry times are shortened to try to adjust to the demand, only to reduce patient safety. In some cases, even the wash and rinse cycles are reduced, with no cycle validation completed to ensure contact over time.
The reality is that the first case of the day receives the highest level of quality assurance; all other instrument sets become subjected to what can be processed rather than a standard of care for the procedures. Surgical employees will tell you to make sure you are the first case of the day in institutions that take shortcuts.
Establishing instrument set conflict times can also be challenging because they are subject to case duration and block time utilization, including room and staff availability. Meanwhile, surgical instrument sets are subject to fixed and varying processing times in SPD. In all, instrument set inventory levels and volume processing are managed in four areas, decontamination, set assembly/sterilizer processing, case cart assembly, and OR core management.
The number of washers to wash racks in decontamination, along with sonic and cart wash utilization, must be measured to total time of through-put. All SPD processing equipment and accessories are subject to time measurements.
Most facilities do not include cool-down of sterilized sets in their equation, which is a critical step in the release of sterilized instruments. Set processing times to fill the loading carts for both decontamination and sterile assembly fluctuates, depending on the complexity and quality assurance of the set, along with the staff’s abilities. Quality assurance needed for complex sets adds time, which is difficult to determine from set to set.
On average, the total cycle time for a given instrument set on a busy day is somewhere between four to six hours (Brooks, 2014). This is subject to fixed and variable times. Fixed times are directly related to total time in a washer or sterilizer, while variable times are subjected to staffs ability to load carts both pre and post washer and sterilizers. Once established, the total processing time becomes the conflict time for all instrumentation regardless of set size or inventory.
You may find that there are sets that have a lower processing time due to the type of instruments such as cameras and scopes, which are subject to low-temperature sterilization; however stick to a standard conflict time.
Once the conflict times are entered for every instrument set, the conflict checker can be activated. The schedulers will start experiencing what is called a “hard stop.” This means that the case cannot be booked until the conflict is resolved. This should result in a group e-mail to a number of key OR and SPD staff who must communicate back to the schedulers as to how to procedure can be booked without delay. In some cases moving a procedure between the conflict times eliminates the problem.
Reviewing the conflicts leads to the purchase or building of additional sets to meet the demand. Instrument set inventory must be adjusted to meet demand through operating expense rather than capital budget for the next year. Revenue loses can occur rather quickly in the form of delays and cancellations.
Additionally, it can cause the loss of business due to the longer time periods between cases. If your surgeons can get their procedures completed faster, they are more likely to add more on, rather than move to another hospital or outpatient center that can get this accomplished. Another report often not used in the OR scheduling system is the instruments for the next day. The report totals all sets on preference cards allowing SPD to see what is scheduled for the next day. Along with the CSC these two management tools provide valuable information for today’s SPD managers.
SPD departments must be able to manage the instrument set inventory to meet demands rather than trying to fit demand into what can be sterilized with short-cuts. The days of having low instrument set inventories that are managed with immediate-use steam sterilization are long gone, or at least they need to be. There are plenty of studies that prove residual bioburden and foreign-body contaminates remain on instruments that receive a fast turnover.
Between the OR scheduling system and the SPD instrument management system there are a number of reports that can support the need for additional instrument set inventory. There also is the ability to interface the two, allowing tracking that provides support for instrument management.
Gone are the days of not knowing how to use software systems tools; they are there for us to use; the time to use them is now. We can no longer manage instrument sets through short-cuts that have high risk associated to them.
Using the CSC portion of your OR scheduling system supports a standard of care for every surgical procedure, not just the first case of the day. Learning to use the systems that support what we do, only adds value to the final outcome — patient safety.
Timothy P. Brooks, BS, CSPM, is manager of sterile processing for the University of Arizona Health Network in Tucson, Ariz.
Reference: Brooks TP. Where are My Instruments and Sterile Supplies? Infection Control Today. Vol. 18, No. 8. Pages 28-32. August 2014.