Making the Choice

Instrument Standardization

By R. Michael Appleby

Standardizingsurgical instruments used in various departments in the hospital can controlcosts, increase instrument processing efficiencies, and help in trainingpersonnel.

The challenge for instrument-using departments today is offering surgeons thespecific instrument they need to perform a procedure, while keeping costs undercontrol. The goal of instrument standardization is to identify one pattern of aspecific instrument to be included throughout all the instrument sets beingused. This facilitates the processing department's ability to replace missing orbroken instruments in instrument sets, and the surgeon's comfort level whenusing standard instruments in different sets. It also reduces training time forprocessing personnel, as there are fewer specific instrument patterns to learn.

Selecting a Vendor
The first decision to make is determining which instrument vendor willbe the primary vendor. National contracts might dictate which vendor you use,but when the choice is not limited, there are a number of factors to consider. Aknowledgeable sales representative from a company that offers a wide variety ofinstrument patterns for a large number of surgical specialties can provideinvaluable assistance in instrument standardization. The vendor should offerinstruments in several quality tiers, so you can purchase the appropriateinstrument for the intended use. Some vendors can provide a computerizedsoftware package to assist in instrument asset management and standardization.

A good computer program should offer an electronic catalog with pictures of amultitude of surgical instruments. Technicians should be able to add instrumentsthat might not be in the catalog but are included in their instrument sets. Thesoftware also should allow technicians to build instrument set "picklists" and print these out for inclusion with the processed sets. It ishelpful in keeping track of instruments that are lost or out for repair, as wellas in creating requisitions for instruments to be purchased. In addition, such asystem should be able to generate a variety of reports to aid in instrumentasset management. Many vendors offer such programs, although some might requirepurchase commitments for advanced versions or value-added features. Once adepartment has selected a prime vendor for its surgical instrument needs, thestaff can begin to standardize the patterns for purchasing.

The Quality Decision
Surgical instruments can be standardized based on quality as well asspecific patterns. Instruments used in the ER or on the floor, which might bethrown out with the trash or stolen, do not have to be of the same high qualityas instruments for the operating room, labor and delivery, or outpatientsurgery. There are a number of cost-effective options for areas that do notrequire the highest quality instruments. These include prepackaged steriledisposable instrument sets, or sets that are made up in-house, using lowerquality instruments, and reprocessed after every use. Decide which is the mostcost-effective choice and which provides appropriate consistency in quality andpattern for the intended use. These patterns may be standardized in the samemanner as first line patterns.

Standardizing Patterns
The operating room, labor and delivery, and outpatient surgery demandsuperior surgical instruments. It's important to retain quality but standardizethe patterns chosen. Generally, the more detailed the procedure, the morespecific the instrument pattern required. There are more than 10,000 hand-heldsurgical instrument patterns that basically perform one of seven functions: tocut or incise, to retract, to grasp/hold/occlude, to dilate or probe, tocannulate or drain, to aspirate/inject/infuse, to suture or ligate.1Many different patterns are available to accomplish the same task. Bystandardizing on basic patterns, expensive duplication costs are eliminated.

Instrument patterns that lend themselves to standardization tend to be moregeneral in nature and are employed for soft-tissue uses in multiple instrumentsets. These include: ring handle forceps and clamps, needle holders, scissors,thumb forceps, and retractors. Because these instruments usually are thehigh-volume patterns purchased, selecting a standard pattern can eliminate a lotof duplication of instrument inventory in the processing department. As patternsfor standardization are selected, be sure to revise the instrument set pick listto reflect the choices made.

Making the Choice

Forceps and Clamps
Ring handle forceps and clamps include towel and drape forceps, spongeforceps and a multitude of hemostatic forceps. Decide which will be the standardpattern for a specific type of instrument. For example, either a Kelly or Crilecould be used if there is a need for a 5" or 6" hemostat. Select oneand make it the standard forceps to be used every time a procedure calls for aninstrument larger than a Mosquito but smaller than a Pean. The same logic wouldapply in determining whether a straight or curved pattern will be used, as wellas the specific instrument type.

Needle Holders
Needle holders should be selected for length and needle holding ability.Select standard patterns for 4-0 and larger, 5-0 to 6-0, and 7-0 and smaller.Surgical instrument sales representatives can recommend appropriate needleholders for each task and help eliminate multiple patterns, making it easier forthe processing department to replace damaged needle holders from inventory.Standardization for specialty needle holders can be achieved by selectinglengths and needle holding requirements for those trays.

Decisions about scissors include length of standard scissors and whether ornot they should be "gold handle" with inserted blades or stainlesssteel blades. All instrument set scissors should offer the surgeon consistency,regardless of the instrument set. A typical choice offering of 4" scissorscould be iris, tenotomy, strabismus, or Metz. Decide on a standard straight andcurved pattern and then use that as the basic scissors selection. Using the samesuture scissors, bandage scissors, or utility scissors in all instrument setsalso helps to reduce costly duplication.

Thumb Forceps
Basic thumb forceps should be selected by jaw configuration and length.Dressing forceps have serrated jaws and tissue forceps have toothed jaws. Selecta standard pattern for each style in the lengths required for the instrumentset. Instead of choosing 5", 5-1/5," and 6" thumb forceps,standardize on one length for short forceps. DeBakey, Cushing, and otherspecialty patterns can also be standardized where they are used in a majority oftrays.

Standardize basic retractors as to width and length, and handheld patternsas to whether they have sharp or dull prongs. Richardson and Kelly retractorsare the same basic instrument except for the size of the blade; the names areoften interchanged. Select specific basic patterns for each blade size requiredand standardize on small, medium, and large retractors. Standardizing onretractors with replaceable blades and/or other parts can reduce the number ofsurplus parts needed to maintain this type of retractor in working condition.

The Instrument Board
Once you have standardized the basic soft-tissue instruments andrevised instrument set pick lists, the processing department should order extrainstruments for their instrument board. The processing instrument board can be apegboard where instruments are hung by type and size; or a cabinet or drawer,where they are separated by size and type. Processing personnel will be able toreplace missing or damaged instruments from the instrument board without havingto take an instrument set out of service or process an incomplete set. Standardinstrument patterns can be ordered in economical quantities, less often, so thatthe staff always has enough of the basics to keep instrument sets in service.Inventory levels should be established for each instrument and stock should bechecked weekly so that orders can be placed for items below ideal level.

Specialty Sets
Specialty instrument sets can also benefit from standardization. Themore a department is able to use the same instrument pattern in multiple sets,the less often mistakes occur in the composition of the sets. Instrument setswill have a more consistent feel for surgeons, regardless of the set they areusing. Charge nurses and surgeons might have to be involved in the making thedecision, but processing and duplicating instrument sets is much easier whenfewer distinct patterns are used within a specialty service.

Benefits of Standardization
Instrument standardization can help control instrument costs byreducing the number of instrument patterns utilized within a facility, therebyincreasing processing efficiencies and making it easier to train personnel. Thereturns realized are well worth the time and energy it takes to standardizesurgical instrument patterns.

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R. Michael Appleby is an instrument asset management Consultant forAllegiance Healthcare Corporation, V. Mueller in McGaw Park, Ill. He has beenassociated with V. Mueller since 1969.

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