Infection Control Today - 07/2002: Instrumental Knowledge

Ask and You Just Might Receive
"Basic set" in one hospital may be"customized" in another. It just depends on where you are and what youare doing

By Michelle Gardner

Dependingon the type of surgery being done, the number of instruments in a set can coverthe basics of the procedure to being prepared for anything with multipleinstrument sets comprising several sizes of devices.

"Some doctors have specialties, like orthopedics and urology, and theyhave instruments for the type surgery they are doing," says Bonnie Ohlrogge,instrument coordinator for The Children's Hospital of Denver (TCH). "Orthodoctors want things like mallets, while urologists might want small needleholders because they are suturing tiny areas."

In the case of TCH, an average major set would include a knife handle,forceps, mosquito and Kelly clamps and various scissors. "The serviceleader designates the instrument set, but we try to make it as consistent aspossible and have them use the same instruments for the same procedures nomatter who the doctor is," explains Ohlrogge. "It helps with inventorywhen we don't have to buy special items."

Predictably, most of the cases at the Denver facility are children, but thehospital has treated adult patients. "We have a lot of differentinstruments depending on the size of the patient," says Ohlrogge. "Wefigure patients 6 years old and younger require one size of instruments andthose older than 6 years have another set. If the case is only done once ortwice a year, doctors may bring items from their hospitals. For instance,dentists do procedures while the child is under anesthesia so it is lesstraumatic."

Sales representatives may offer a doctor the use of their specialized sets,which allows them to avoid extra inventory and only pay for what they use."Service leaders talk to the doctors and order necessities for aprocedure," says Ohlrogge. "If the doctor needs plates that we don'tcarry, the sales rep will bring them in. The items go through decontaminationand we give them back to the rep. It is kind of a renting system."

But Sometimes, You Can't Have It All

It is common to have customized instrument sets at University of IowaHealthcare in Iowa City. "We have lots of customized sets here, so I am notsure if they qualify as customized any more," says Mike Murphy, manager ofcentral sterilizing services. "Our computer system can compare twodifferent sets and tell us what is different, and we can enter a set name andthe system will tell us the differences in the sets."

Murphy does point out that a hospital's location may dictate how things aredone. "I live in a small town, but we have a huge medical center," hesays. "We get physicians who come here to practice and the medical centerallows them [to ask for specific instruments]. I think the market dictates someof the customization."

Just like instrument sets depend on the type of surgery being performed,every physician is trained differently. "If you get a physician fromMichigan and another from California, they have been trained two different wayswith different systems," says Murphy. "They use different instrumentsto complete the same process, doing it equally well. They use different thingsin different parts of the country."

While medical institutions would like to give doctors an opportunity to usedifferent instruments, they are restricted by inventory and budget. "Weonly have two hip systems out of five or six (that are available), but we can'tafford to have them all," shares Murphy. "If a physician goes fromhere to Michigan, he or she may have a completely different hip set."

Similar to TCH in Denver, University of Iowa Healthcare standardizes itsbasic sets. "They are assembled ahead of time so when a physician tells uswhat they would like [to use] we try to put it together," says Murphy."It is possible we can give them an existing set. Plus, using the computerprogram, we can tell what instruments are in a set, then add individualinstruments [to complete the requested set]. On any given procedure they areusing only 40 percent of the instruments, but in the course of all theprocedures, they may use 100 percent of the instruments."

It can be a difficult task to distribute instruments among sets that getsurgeons through a day, yet not waste instruments in trays. Even custom sets mayhave surgeons asking to add two or three items. You can easily end up with moreinstrument sets that must be tracked and increase inventory costs considerably.

Orthopedics poses the greatest dilemma because there are so many bones andsizes. "When you get into implants, screws and systems, there is no way topredict usage or what is commonly used," says Murphy. "You can't doaway with ortho systems. If you need to replace a hip, you need the hardwareremoval stuff from the old system to get the hardware out. To keep it all instock and up to date is the hard part."