Instruments Missing In Action
By Marcia Frieze
Nationally, operating staffs are reporting that a number of instrument trays are incomplete or inaccurate. Both CS and OR staffs are frustrated and morale is low. Surgeons are upset and vocal. And, surgical cases and turnover time are increasing. The following could be a typical scenario at any American hospital:
An instrument is missing. The patient is prepped and ready for surgery. The OR calls CS and says it is responsible for the incomplete set. Meanwhile the missing instrument creates delay and scheduling problems for the OR. CS claims the instrument was never returned from the OR. Maybe OR staff threw it out with the wrap. The OR manager remembers that the doctor sometimes takes it to ambulatory for out-patient surgery or puts it in his locker for later use. Everyone agrees that the problem is the budget allows for too few instrument because of cost. Meanwhile, existing instruments are hard to find because too many sets are disorganized, poorly labeled, or contain instruments not needed for this procedure.
The challenge for instrument processing departments has been to offer the OR the specific instruments needed for a procedure on time, properly processed, and with the correct count. Missing or damaged instruments create confusion, lost time, and stress for staff trying to locate the missing instruments. Having organized, easy to clean, and effective tray systems can certainly help. Knowing where surgical instruments are at all times is crucial due to the complexity of current instrumentation, the cost of the newer devices, and the speed required to process instrument sets. Instrument management systems are a proven way to track surgical instrument sets, but they are costly to purchase and maintain, and are only as good as the staff dedicated to inputting the data. Therefore we will focus on less costly and less labor-intensive options, such as standardization, organized tray systems, and visual aids such as count sheets, custom graphics trays, and a photo layout or map program for instrument sets.
Recent trends in healthcare toward greater management of resources and a decrease in instrument inventories require that healthcare professionals as well as manufacturers work together to identify policies and procedures, as well as devices to address current needs. This requires a climate of communication, problem-solving, and teamwork to identify and implement solutions. Standard operating procedures in healthcare facilities are under review. Creative new solutions can only emerge in an atmosphere of cooperation and openness.
Successful surgical procedures require a group effort--a team of caring professionals with different responsibilities. The combined effort of the team will ensure high-quality patient care and reinforce good working relationships. The OR relies on CS for sterile instrumentation and supplies as well as patient ready equipment. CS needs the OR staff to return the sets free of bioburden and with all components in place. Yet what we see in practice are very densely packed sets that are hard to sterilize, with instruments that are hard to find.
Most often surgical instruments are placed in deep baskets. Most are not identified or labeled. The sterile processing manager at Alaska Native Hospital, Dawn Freeman, asked us for help in organizing a large instrument set. She sent us the instruments in question. Upon receiving a picture of the set containerized and organized into layers via e-mail, she questioned whether the set was complete. "It looks good, but where are all the instruments?" All of the instruments were present; none were missing. An organized set looks lighter, less confusing, and is easier to manage and facilitates the instrument count. In addition, it can save money. According to Jim Heller, manager of sterile processing at Sarasota Memorial, "Nearly $90,000 was saved when the hospital went to an organized tray system with protective inserts." The greatest savings was a reduction in scope repair.
If standardized tray systems can save money and reduce stress and conflict among staff, why is it that few hospitals that are containerized have not necessarily customized and standardized as well? The answer is complex. First, going to a customizable tray system requires an initial capital outlay. It involves the cooperation of the team to plan, implement, and agree to implement change. Change, even change for the better, is difficult. It requires a willingness to make process changes such as doing a physical inventory and to gain the cooperation of a dedicated, committed group of decision makers. Successful surgical procedures require a group effort, as does initiating change. It requires initiative and motivation. Start with a team of competent and caring professionals and a plan of action. This should be a joint project between CS and the OR. This is necessary because each department will be looking for different features and benefits. Each must be comfortable with the final choice.
At a recent program in North Carolina which focused on service excellence, the most frequent response from CS professionals as to a need for improvement in service was the issue of communication with the OR. The conflict over missing instruments was viewed as a major contributor to the increasing conflicts. Most of the participants felt that communication and problem solving were needed to resolve their problems with the other department and to reduce stress and conflict amongst staff.
Simplifying instrument sets saves time and money. Furthermore, standardization reduces duplication, excess inventory, and costs. Organized instrument sets not only reduce confusion and clutter, but also weight. Think of how many instruments have been added to a tray over time. The doctor may have left the service or retired, yet the excess instrumentation is still packaged. By simplifying sets we are actually increasing our inventory of instruments that can be used to make duplicate sets or added to new instrument sets. It is difficult, if not impossible, to put a price tag on the peace of mind that stems from knowledge that surgical instruments have been properly packaged, correctly processed, and in place for use.
Standardizing and simplifying instrument sets are a necessary first step. Documenting the decision in writing by way of a count sheet or instrument listing is crucial. Adding a tray layout or a print or photo of the instrument gives a visual check. This can be included in an instrument management program that is computer generated or simply laminated and attached to the count sheet as a road map. Some custom trays, such as those designed for custom orthopedic tray systems, are organized in fixed layouts with specific graphics etched or silk screened on the tray. The instruments are easily identified, but no allowance is made for change or replacement. Some tray manufacturers offer a modular tray system that can be customized, labeled, and adjusted as the need arises. Modularity allows the user to reconfigure existing parts and components.
Further, instrument sets must be protected from tampering. Packaging, whether wrap or sealed containers, must have a seal or tamper proof lock to secure the package. Labeling, whether bar code or written, copy helps identify that the correct set has been selected. Labeling the contents, identifying the number of instruments in the set, bar coding, and color-coding are a few ways to identify contents. Layering trays, putting heavy instruments in the base, partitioning light from heavy instruments, and placing those used first on top are a few simple steps that staff can implement to better organize contents.
As an option, more healthcare facilities are considering rigid sealed containers, which are reusable, thus reducing reprocessing costs. Furthermore sealed containers decrease the risk of damage or loss of costly instruments during transport and handling. One might consider transporting instruments from the OR to decontamination after a procedure in a secure, tamper proof container. Although rigid sealed containers may cost more initially than other sterilization trays, the advantages of easy handling and increased productivity if trays within the container are properly organized more than compensate for the initial investment. Furthermore, instrument set identification is easier with color-coded nameplates, bar coding, and identification tags. Purchasing a compatible product, which can perform in today's newer sterilization systems, is a definite advantage. Be sure what you buy is durable and universal. In terms of environmental benefits, a sealed container generates 99% less waste than disposable wrap and reduces the amount of regulated waste.
The goal of instrument processing is to serve the patient. If we can successfully address the problem of instruments missing in action, we have made our lives easier, reduced conflict and stress among staff, while saving money for our facility, and providing a better level of care to our patients. Isn't this what healthcare service excellence is all about?
Marcia Frieze is CEO of Case Medical in Ridgefield, N.J.