Instruments Missing In Action

December 1, 2001

Instruments Missing In Action

By Marcia Frieze

Nationally,operating staffs are reporting that a number of instrument trays are incompleteor inaccurate. Both CS and OR staffs are frustrated and morale is low. Surgeonsare upset and vocal. And, surgical cases and turnover time are increasing. Thefollowing 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 themissing instrument creates delay and scheduling problems for the OR. CS claimsthe instrument was never returned from the OR. Maybe OR staff threw it out withthe wrap. The OR manager remembers that the doctor sometimes takes it toambulatory 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 instrumentbecause of cost. Meanwhile, existing instruments are hard to find because toomany sets are disorganized, poorly labeled, or contain instruments not neededfor this procedure.

The challenge for instrument processing departments has been to offer the ORthe specific instruments needed for a procedure on time, properly processed, andwith the correct count. Missing or damaged instruments create confusion, losttime, and stress for staff trying to locate the missing instruments. Havingorganized, easy to clean, and effective tray systems can certainly help. Knowingwhere surgical instruments are at all times is crucial due to the complexity ofcurrent instrumentation, the cost of the newer devices, and the speed requiredto process instrument sets. Instrument management systems are a proven way totrack 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 wewill focus on less costly and less labor-intensive options, such asstandardization, 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 inhealthcare toward greater management of resources and a decrease in instrumentinventories require that healthcare professionals as well as manufacturers worktogether to identify policies and procedures, as well as devices to addresscurrent needs. This requires a climate of communication, problem-solving, andteamwork to identify and implement solutions. Standard operating procedures inhealthcare facilities are under review. Creative new solutions can only emergein an atmosphere of cooperation and openness.

Successful surgical procedures require a group effort--a team of caringprofessionals with different responsibilities. The combined effort of the teamwill ensure high-quality patient care and reinforce good working relationships.The OR relies on CS for sterile instrumentation and supplies as well as patientready equipment. CS needs the OR staff to return the sets free of bioburden andwith all components in place. Yet what we see in practice are very denselypacked sets that are hard to sterilize, with instruments that are hard to find.

Most often surgical instruments are placed in deep baskets. Most are notidentified or labeled. The sterile processing manager at Alaska Native Hospital,Dawn Freeman, asked us for help in organizing a large instrument set. She sentus the instruments in question. Upon receiving a picture of the setcontainerized and organized into layers via e-mail, she questioned whether theset was complete. "It looks good, but where are all the instruments?"All of the instruments were present; none were missing. An organized set lookslighter, less confusing, and is easier to manage and facilitates the instrumentcount. In addition, it can save money. According to Jim Heller, manager ofsterile processing at Sarasota Memorial, "Nearly $90,000 was saved when thehospital went to an organized tray system with protective inserts." Thegreatest savings was a reduction in scope repair.

If standardized tray systems can save money and reduce stress and conflictamong staff, why is it that few hospitals that are containerized have notnecessarily customized and standardized as well? The answer is complex. First,going to a customizable tray system requires an initial capital outlay. Itinvolves the cooperation of the team to plan, implement, and agree to implementchange. Change, even change for the better, is difficult. It requires awillingness to make process changes such as doing a physical inventory and togain the cooperation of a dedicated, committed group of decision makers.Successful surgical procedures require a group effort, as does initiatingchange. It requires initiative and motivation. Start with a team of competentand caring professionals and a plan of action. This should be a joint projectbetween CS and the OR. This is necessary because each department will be lookingfor different features and benefits. Each must be comfortable with the finalchoice.

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 inservice was the issue of communication with the OR. The conflict over missinginstruments was viewed as a major contributor to the increasing conflicts. Mostof the participants felt that communication and problem solving were needed toresolve their problems with the other department and to reduce stress andconflict amongst staff.

Simplifying instrument sets saves time and money. Furthermore,standardization reduces duplication, excess inventory, and costs. Organizedinstrument sets not only reduce confusion and clutter, but also weight. Think ofhow many instruments have been added to a tray over time. The doctor may haveleft the service or retired, yet the excess instrumentation is still packaged.By simplifying sets we are actually increasing our inventory of instruments thatcan be used to make duplicate sets or added to new instrument sets. It isdifficult, if not impossible, to put a price tag on the peace of mind that stemsfrom knowledge that surgical instruments have been properly packaged, correctlyprocessed, and in place for use.

Standardizing andsimplifying instrument sets are a necessary first step. Documenting the decisionin writing by way of a count sheet or instrument listing is crucial. Adding atray layout or a print or photo of the instrument gives a visual check. This canbe included in an instrument management program that is computer generated orsimply laminated and attached to the count sheet as a road map. Some customtrays, such as those designed for custom orthopedic tray systems, are organizedin fixed layouts with specific graphics etched or silk screened on the tray. Theinstruments are easily identified, but no allowance is made for change orreplacement. Some tray manufacturers offer a modular tray system that can becustomized, labeled, and adjusted as the need arises. Modularity allows the userto reconfigure existing parts and components.

Further, instrument sets must be protected from tampering. Packaging, whetherwrap or sealed containers, must have a seal or tamper proof lock to secure thepackage. Labeling, whether bar code or written, copy helps identify that thecorrect set has been selected. Labeling the contents, identifying the number ofinstruments in the set, bar coding, and color-coding are a few ways to identifycontents. Layering trays, putting heavy instruments in the base, partitioninglight from heavy instruments, and placing those used first on top are a fewsimple steps that staff can implement to better organize contents.

As an option, more healthcare facilities are considering rigid sealedcontainers, which are reusable, thus reducing reprocessing costs. Furthermoresealed containers decrease the risk of damage or loss of costly instrumentsduring transport and handling. One might consider transporting instruments fromthe OR to decontamination after a procedure in a secure, tamper proof container.Although rigid sealed containers may cost more initially than othersterilization trays, the advantages of easy handling and increased productivityif trays within the container are properly organized more than compensate forthe initial investment. Furthermore, instrument set identification is easierwith color-coded nameplates, bar coding, and identification tags. Purchasing acompatible product, which can perform in today's newer sterilization systems, isa definite advantage. Be sure what you buy is durable and universal. In terms ofenvironmental benefits, a sealed container generates 99% less waste thandisposable wrap and reduces the amount of regulated waste.

The goal of instrument processing is to serve the patient. If we cansuccessfully address the problem of instruments missing in action, we have madeour lives easier, reduced conflict and stress among staff, while saving moneyfor our facility, and providing a better level of care to our patients. Isn'tthis what healthcare service excellence is all about?

Marcia Frieze is CEO of Case Medical in Ridgefield, N.J.