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By John Roark
Replacing even one surgical instrument in a set can costhundreds of dollars. Juggling the rising cost of instrumentation with shrinkingbudgets and heat from the operating room (OR), the value of a pro-active careand repair program is worth its weight in gold.
The most important thing to focus on is why we take care ofthe instruments, says Richard Schule, BS, CST, CRCST, CHMMC, FEL, manager ofthe surgical processing department at the Cleveland Clinic. We do a lot ofeducating, and yet from time to time well see someone carrying a tray ofinstruments by the handle on its side like a suitcase, and the contents flopover. Its like, what was the point of all of that? Or when they finish theprocedure, theyre breaking down the back tables and they put the heavyinstruments on top of the delicate items to come down into reprocessing. I thinkyoure always a cheerleader to promote good care and handling techniques. Itsa never-ending process continual reeducation and hammering that into theforefront of the mind.
New instruments should be visually inspected upon purchase andinserviced prior to use. If you are a person who knows the instrument, youwant to look at it, make sure that its in good working order. Make sure itssharp if its a cutting instrument, or that it retracts if it should, says Rose Seavey, RN, MBA, CNOR, ACSP, immediate pastpresident of the American Society for Healthcare Central Service Professionals(ASHCSP) and director of the sterile processing department at The ChildrensHospital in Denver. I also make sure that any new instruments go through thewasher before they get used.
If its a complicated instrument like a da Vinci surgicalrobotic arm, you really want to go through all of its working elements and makesure that it does work. Or if its a drill or power instrument, put it throughall of its motions and make sure that it works before you wrap it and sterilizeit.
We make sure that all of the pieces are there, and that theinstrument actually functions as its supposed to, says Carla McDermott,RN, technical advisor for the International Association of Healthcare CentralService Material Management (IAHCSMM). Some of these instruments sit in awarehouse for awhile. Weve received some that were rusty right from thestart, and we ship those right back. If we werent given the opportunity toinspect them, wed never be able to prove that we didnt damage them. Youjust need to make sure that its a usable instrument and that theres nodamage to it, and that youve got all the pieces.
If its a new instrument or product, you need to be surethat you have the sterilization and flash instructions for that product, and todo the education with the staff, continues McDermott. If youve got a newwidget, youd better be telling everyone what it is and where it belongs, oryoull never see it again. That includes the OR staff as well. There has to be an education component whenever you get newtoys.
Becki Harter, CST, RCST, CRCST, FEL, president and CEO ofSterilization By Design, tackles instrumentation cost on four fronts: care andhandling, packaging, instrument repair rotation and par levels.
Theyre all important, says Harter. You have tohave all of those components to make it work. If you dont have good care andhandling, your repair bills are going to be high. You cant have a greatrepair/refurb program but have thousands of instruments on your shelf that youdont need. You cant have a good par level, and then go to a repair/refurbcompany thats not original equipment manufacturer (OEM) certified. Youvegot 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:
Harter recommends that managers and associates in centralprocessing departments make a quarterly review of problem areas in care andhandling. Training that is focused on problem areas should be developed,implemented and maintained, and attended by all central processing and clinicalassociates.
Difficulties can arise when trying to assess the processingneeds of an instrument, says Harter, who recommends asking the followingquestions when devising a plan of action for the care and handling ofinstruments:
The answers to these questions play an integral part in theincrease or decrease of the costs required to maintain the integrity of aninstrument.
Seavey stresses the need for consistency when packaging. Alwaysdo it the same way, she says. Get into the routine and learn the best wayto protect the instruments. When you pack them in a container, be very careful.Not only when youre putting the sets together, but when theyre comingdownstairs. We have a great working relationship with the OR, but if a set comesdown and it does not come down protected if youve got mallets and otherheavy instruments on top of the delicate instruments we will call up to theOR and ask them down, or we take a picture of it if we can, and send it up andsay, Look how this was treated. We keep a digital and an instamatic camerain the department at all times.
Every storage/sterilization management system (SSMS) should becarefully evaluated before purchase. Factors to keep in mind are:
Instrument Repair Rotation
Pro-active, preventive maintenance should be aggressivelymonitored, and can cut down on the frustration resulting from compromisedinstruments making their way into the OR, says Seavey. Frustration all theway around of the doctors, nurses, the techs when they get screamed atbecause somethings not working,. The surgical case goes better because thedoctor always has a good working tool, and theres more reliability and itresults in a better working communication.
We have a spreadsheet. All of our trays are labeled withnumbered, stainless steel tags, says McDermott. We know which number traywent out last. On the spread sheet I have all the different trays, and I havethem 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 andminor trays that are used 15 times a day, every day, and I have neurosurgerytrays that get used twice a month. I have adjusted on that spreadsheet when theyare due, based on usage. Of course, if somebody complains about something on atray, we take care of that immediately.
Monitoring rotation can be done low tech especially ifyouve got a person who deals with sending out your repairs all the time,says Seavey. Maybe your instrument supervisor deals with the same person whocomes 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 ofinstrumentation tracking through the use of bar codes. A rotation schedule canbe set up through software which will generate reports tracking monthly repairs,or set up an annual schedule ensuring that instruments are touched multipletimes once a quarter, twice a year, whatever the customer dictates.
McDermott looks forward to implementing a bar coding systeminto her facility. Its going to make a lot of things more efficient,she says. Because of all the VCJD business going on, were going tobe challenged to track these instruments to the patient. At present, thatsnot a possibility. Even if I had to only track my neurosurgery instruments anddrills, I would be hard pressed to do that manually. The bar coding will makethat 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 becauseI dont have enough instruments. You need to buy two more cut-down trays, ortwo more pacemaker trays, because its inappropriate to be flashing thesethings. These are routine instruments.
Problematic items become routine items because youve setit up into the system when youre going to send instruments out on a regularbasis, says Schule, endorsing bar code tracking systems. When yourcustomer, the end user the surgeon in this case starts to complain thattheres a problem, we can tell them well up the sharpening schedule. Well rotate set A out for set B, and you wont have aproblem.
If an instrument is on a regular rotation for inspection, thenature and cost of any refurbishment or repair is significantly less over time,says Harter. As the instrument is consistently maintained, the need for majorrepairs decreases, decreasing the overall cost.
Maintaining par level prevents instrument sets from being outof service while an instrument is being repaired, helps identify high usage orloss of instruments enabling management teams to address problem areaseither by increasing inventories or by identifying the cause of loss, anddeveloping a plan of action to prevent that loss. Par level also clarifies anditemizes instrumentation expenditures.
I go into hospitals and I see thousands of instruments thatthey dont use, says Harter. Its crazy to have those on the shelf. Iknow of a couple of companies that buy and sell instruments for third worldcountries. I tell the hospitals: lets sell to them, see if they have anythingyou need trade for that, or buy something that you can use with thoseinstruments rather than let them sit on the shelves collecting dust. Youre refurbishing them once a year for what? If threemonths later its got dust on it, thats telling you something: you dontneed it. My point is if you havent seen it, if you dont even remember whatit is, you dont need that instrument. I understand that it takes time to getthat scaled down, but its very well worth the effort. At the hospital where Icurrently 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 alot of hospitals that have stuff that theyve never seen, used, or know thecost of.
Harter recommends the following steps to effectively monitorpar level:
When shopping for an instrument repair company, look forconsistency, thorough knowledge and legitimate references.
Weve been with the same company and had the same repairperson for more than 20 years, says Seavey. I look for consistency,trustworthiness I dont want somebody to come in here and do additionalrepairs that I dont need. I want somebody that will come in and work side byside 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 coupleof years. I want somebody who has a solid knowledge base I really want tosee their credentials, what kind of training that they actually have didthey just learn it in a garage? If I was going to switch companies, I wouldcertainly want to call many of their customers and get some feedback. Not justany references, but references of people I know.
Harter advises: let the buyer beware. There are somecompanies out there who have literally gone to their own garages to do the work,and theyve destroyed thousands of dollars worth of instruments, either bydiminishing their life or by destroying them, and calling it the hospitalsfault, she says. There are one or two companies out there that aresharpening things every time they put their hands on them. Theyre doing itevery week. Youre doing something that is supposed to prolong the life, butby doing it too much youre actually shortening it. There is such a thing asover-refurb, and I think that people should be cautious about that.
Harter also cautions against companies that charge forinstrument evaluation in addition to any repair work done. Thats crazy.The customer should only be charged for the actual work done, not for justlooking at the instruments. There are companies out there refurbishing just forthe sake of refurbishing when the instrument may not need it. You have peoplecharging as much as $5 or $10 per instrument just to look at it. The averageinstrument set has 100 instruments in it. Somebodys making some money.Somebodys losing some, too.
There are companies out there that dont charge you forthe evaluation of the instrumentation. In fact, theyll do a routine cleaningand make them look nice, and they wont charge you for that unless theyactually have to do something to repair a box lock or sharpen it. Those are thecompanies that you need to keep.
Mobile repair companies offer the convenience of on-siterepair, resulting in quicker turnaround.
Flexibility is the main thing with my customers, saysSchule. Ive got surgeons who at the drop of a dime want something done. Ilook at flexibility, quality and the education of the individual performing theservice. And then finally comes cost. Thats the difference dependingon what hat youre wearing. Some people look at cost first; Im not aproponent of that.
Integrated Medical Systems (IMS)
MobileInstrument Service & Repair
TheScope 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