Steps in the Management of Surgical Instrumentation

Key assets directly related to revenue in today’s surgery departments is the management of a vast inventory of surgical instrumentation, equipment and supplies. Instrumentation, along with rigid and flexible scopes in a 350-bed hospital with a 14-suite surgical unit, can easily exceed $5 million. The number of instrument sets can hover around 400 and account for some 10,000 or more individual instruments that require special attention.

Operating budgets and capital expenses can soar to as much as $500,000 in new and replacement instruments costs annually due to poor management and high use of flash sterilization. The challenge to turn over rooms as fast as possible to achieve that magic number so desired by surgeons to expedite the next case leads to instruments going straight into the trash.

With the added cuts looming on the horizon, hospitals need to shed older-style management structures and become more business-focused on a service-related support system for managing surgical instruments and equipment. Hospital materials managers’ primary area of expertise lies with supply management, ensuring best price and contract compliance with little time or ability to address surgical instrumentation and operating room (OR) equipment. This is mostly due to the sheer volume and logistical nightmares of stocking supplies throughout hospitals.

The ability for hospital materials managers to get into the OR is also not an easy task, which is mostly due to the closed-door environment of surgery and an age-old separation between the two services. Central sterilization (CS) tends to get caught in the middle somewhere between blame and helplessness with little — if any — ability to make positive change, so some would think.

A surgical services materials management program properly structured to include CS can greatly improve surgical throughput and provide valuable data to support future growth while reducing waste. Who knows better than CS the need to manage surgical instruments; after all, CS personnel handle the bulk of them but have little ability to adjust to demand.

Now, to make matters more challenging, there is little benchmarked data to support a ratio of the number of instruments sets needed to support the daily OR schedule. Achieving the correct amount can be difficult and frustrating for all parties involved — surgeons, administrators, nurses, scrub techs and sterile processing (SP) personnel.

Surgeons expect to schedule and complete cases without delays while administrators want to ensure a profit to allow future growth. Nurses and scrub technicians just want to get through a day’s schedule error free with as few complaints as possible, with more focus on patient care than tracking down instruments.

Managing the instrument inventory generally is not related to who should be doing it rather than who wants to do it. Building a surgical services materials management program to include supplies and equipment with SP managing the instrument inventory only makes sense. As it stands, SP handles all of it, more so than any one group ever could imagine.

If given the chance, SP professionals can greatly improve the process when all the steps involved are known and followed. They can also tell you which instruments are in the highest demand due to requests to turn them over and over again.

Too often, key steps are missing because the process is fragmented between SP, surgery, and the number of users of instrumentation throughout the hospital. The emergency department, cath lab, NICU, and nursing units all have instrument management needs but do not want to hassle with it, let alone decide how much instrumentation to have.

In order for effective instrument management progress your hospital administration and surgery leadership must support the centralized approach to managing the inventory. The steps to complete such a task are not as impossible as they may seem and in most case are as easy as 1-2-3.

Step 1:

Centralize the management of surgical instruments under the leadership of one entity. Allowing the management of materials, be it supplies, equipment, or surgical instruments to be split between services, reduces one’s ability to associate them collectively to the end service, pulling cases for surgical procedures. Instrumentation is one part of the service-related function SP must have full control of, along with the authorization for the purchasing and operating budgeting of all surgery-related instrumentation.

Step 2:

Listen to the SP staff and scrub techs, as they know better then any manager what’s needed. A seasoned surgical scrub professional knows which sets are flashed daily whereas a CS tech will have knowledge as to how many instruments sets are needed to support the OR schedule. They can tell which instruments cause the most interruptions during the day as well as what is needed in your facility’s routine back-up instrument inventory.

Step 3:

One of the tools that we have available to SP but rarely ever use and in some cases not even known about is the use of equipment-conflict checking in the OR scheduling system. When used properly this somewhat simple step can solve instrument turnover problems, aid in the reduction of flash sterilization, and improve room utilization.

The SP department will need to educate itself to the OR scheduling process by sitting down with the scheduling office staff and finding out what takes place when cases are scheduled. Understanding block scheduling and room turnover will also help you improve instrument throughput.

Next, you must educate the schedulers to understand how over-booking causes shortcuts to occur, all in the name of keeping surgeons happy. Schedulers generally do not know how much instrumentation is in the system and make decisions based on pressure to get the case scheduled. They also have the ability to skip the instrument conflict without approval which should not be allowed. When the scheduler gets an instrument conflict they need to contact SP or the instrument coordinator for approval. An experienced instrument coordinator will be able to make necessary adjustments to meet demand or make the decision that it cannot be done in the name of patient safety.

Included in step three is building a conflict time for every instrument and piece of equipment in the OR. Steam and Sterrad items generally take about the same amount from decontamination to sterilization to placing them on the shelf for use; about three-and-a-half hours total for one item. This is measuring sterilizer operating times and any manual times associated to one item along with automated washers.

This time is associated to every step in the process, from receiving in decontamination, disassembly, manual washing, sonic, automated washer, cooling, drying, preventive maintenance (PM) testing, assembly, and sterilization, including putting items back on the shelf for the next case. The problem is that we do not process one item at a time. To ensure that we are maximizing through put we need to manage fully loaded washers and sterilizers.

The result is the need to measure wait times which are associated to filling the washers and sterilizers. This time varies depending on the daily schedule and complexity of the instrument sets coming through the system. Disassembly and assembly of instruments as well as pre-package PM testing is also part of this time and should never be shortened.

Time is also associated to the ratio of the number of washers, sterilizers, washer/sterilizer carts, and the instrument inventory, or the lack thereof. It’s not as difficult as it sounds. Your average 350-bed hospital completing 10,000 to 15,000 surgeries per year may have a total time of about 4.5 hours, which becomes the equipment conflict assigned to every instrument or instrument set in the OR scheduling systems inventory database, about 1,250 total items.

By adding this time to the OR scheduling systems conflict checker the schedulers now know that when they get an equipment conflict they have to get approval from SP and may have to re-schedule and not over-book.

Before implementing an equipment conflict time you will need to educate the OR staff, including surgeons, as to how long your processing time is. They will understand this when presented to them in a professional manner. Remember, surgeons and OR staffs truly have little knowledge of SP problems and challenges until we teach them. Understanding how to use conflict checking is one of the many aspects of SP that is overlooked due to our lack of involvement with the OR and the surgical instrument inventory.

Once implemented, your processes in SP will almost instantly improve. You will find the tray errors and lost instruments will almost completely stop. SP staff will be less inclined to take short cuts and surgeons' complaints will decrease.

Step 4:

SP must know as much as possible regarding the surgeon preference card and the supporting data management in the OR scheduling system. Descriptions in the OR system must drive the count sheet, shelf label and package label, and they all must be the same. If you are using an automated instrument tracking system, the description in it must be derived from the OR preference card system without exception. Assigning the instrument and equipment data-building for the preference card should also be part of the surgical materials management function.

Step 5:

Utilize an instrument count sheet system under the management of one person, preferably a manager or an experienced instrument tech; do not allow everyone to have access. There are programs in the marketplace that are free or can be negotiated; your primary instrument vendor is often the first place to start. In most cases you may need to commit volume to one vendor to get the program at no cost.

Instrument management can be best served by budgeting for an integrated system that can be part of an OR integration package to allow surgical staff the ability to view instrument sets in the OR and in SP. Instrument tracking systems are often interfaced with the OR scheduling system, providing real-time utilization.

All instrument tracking system providers will use your Word or Excel count sheets and build the database for you. In some cases the vendor will complete an inventory and build the data base from that. Make sure you standardize your count sheets to one primary vendor with a secondary for those hard-to-get instruments. Do not substitute from another vendor unless you change the count sheet to match the instrument.

You will minimize errors and improve employee training by keeping your count sheets accurate, following the vendor catalog numbers. Granted, the catalog numbers will wear off the instrument over time if extensive repassivation is required due to poor decontamination processes. Keeping the database descriptions standardized and simple will also reduce errors as well as and speed up training.

Do not allow made-up names or pet names; use the proper industry name of the instrument, and do not use the instrument manufacturer’s technical descriptions. Start all descriptions with common nouns, such as scissor, needleholders, forceps, retractors, and so on. Count sheets that follow a specific organization that can be standardized will greatly improve the assembly process. The proper noun is to follow with type and size as follows, “Scissors Mayo CVD 6.5.” Keep it simple!

Adding the vendor catalog number to the end of the description will also help. Keep a master copy with a picture on file along with sterilization instructions in SP for sets that require additional attention. All changes are to be signed-off and kept on file with the original.

Special note: An instrument tracking system in place of a count sheet system can provide additional utilization information but requires IS justification to purchase. There is much to consider when moving to a tracking system. Purchasing a tracking system to track single instruments is not adequate justification.

Make sure you understand what extra steps there are before undergoing the purchase. If you are planning to use the system to prove that it is the OR that is losing instruments, then do not proceed any further. Casting blame is not the answer; controlling and managing the surgical instrument inventory eliminates the blame game and reduces lost instruments.

Step 6:

Get full control of flash sterilization; this means that you need to staff someone on both shifts in the OR to manage the process. Instrument coordinators who have full control over flash, System-1, and scope management will save your hospital thousands of dollars. By having someone in the OR managing the daily instrument needs, you will also be able to pinpoint where additional sets are needed and address repairs much more accurately. If you are relying on flash sterilization to turn over instruments, then you do not have enough inventory to support a standard of care. Budget and purchase more.

Address one-of-a-kind instrument sets, if you are flashing them between cases, then purchase additional sets. The excuse that we only have one set or that we cannot afford an additional set does not support a standard of care. Flash sterilization adds time to the daily OR schedule and can directly affect room turnover, which costs the hospital money and reduces surgeon satisfaction. Too often short cuts are taken with the washing of instruments in preparation for flash sterilization, for which the Association of periOperative Registered Nurses (AORN) has noted in its standards.

Special note: Do not allow your consignment orthopedic vendors the ability to wash and flash-sterilize their instrument sets. If at all possible, add all consignment sets to your count sheet system with pictures kept on file in SP and in the OR.

Step 7:

Have an on-demand instrument needs-list report printed from the OR scheduling system. The information is available in the OR scheduling system by requesting the cases for the day and the corresponding preference card equipment database. The report needs to be reviewed three times daily. Review before the first case of the day at the OR shift report, the second during the SP shift change, and again at the end of the day. We are not talking about hour-long reviews — the morning review is completed during the OR shift report to look for add-on cases; the second review is 15 minutes during the SP shift change; the third is completed by the night shift instrument coordinator before leaving for the day and posted for the morning shift to close out. Understand that communication between shifts is crucial to attend to instrument problems and addressing consignment instrument utilization.

Special note: Knowing what consignment or loaner sets are coming or going is critical to ensuring that they are handled in the same manner as any other set before being used on a patient.

Step 8:

Utilize the OR scheduling system to access set usage; the information is there, you just need to know how to retrieve it. In some cases there is a report writer in the system that can do just that. Hopefully your OR has a dedicated IS person responsible for the system. Knowing the utilization will help you to purchase additional sets or move sets to other surgery related services such as out patient surgery center. A tracking system will also provide the same information.

Step 9:

Utilize on-site instrument repair services and get to know your sterilizer repair professionals. These people can educate your staff and help you solve all kinds of problems. They can also teach you about repairs and preventive maintenance, along with getting you in contact with custom manufacturers that can fix or make just about any surgical instrument.

Step 10:

Teach your staff how to do PM on light cords, rigid scopes, and air-powered instruments. Purchase a simple CORBA light source and a Rigid-Scan rigid scope checker and start checking fiber optic light cords as well as rigid scopes prior to sterilization. These two devices will help you eliminate complaints regarding both items by identifying the problem before it shows up on the sterile field. Be proactive and complete preventive maintenance as often as possible. It also goes without saying, do not forget to conduct routine PM on scissors and needleholders.

Step 11:

Do not allow surgeon-named trays, which generally increases flash sterilization due to lower inventory levels. In most, if not all hospitals, there is almost always one physician-named tray which is flash sterilized from patient to patient. By doing so your hospital is supporting routine use of flash sterilization. This process must stop because of the risk to patients, reduced instrument life, poor manual wash, and increased time added to the daily room turnover. Routine flash sterilization use is not supported by a number of industry organizations, including AORN, the Association for the Advancement of Medical Instrumentation (AAMI), the American National Standards Institute (ANSI), the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and the International Association of Healthcare Central Service Materiel Management (IAHCSMM). The focus must be on the instrument inventory which, if managed correctly, will reduce and even eliminate the need for flash sterilization altogether. Standardize your trays and purchase enough so that your surgeons can complete the cases without delay.

Step 12:

Review the entire decontamination process, and understand that if you are sending instruments to surgery with rust or blackened staining in the box-lock area, then you have a serious breakdown in the washing process. If ever there was a process that should be specialized it would be decontamination. Maintaining consistent staff in this area will produce significant dividends. A well-organized and operating decontamination will increase prep and pack out-put. Decontamination, conflict checking of instruments are the two most important aspects of the surgical materials management instrument throughput. Developing a well-rounded instrument management program takes time and persistence but will produce positive patient outcomes.

Surgeon satisfaction generally leads to increased volume and retention of staff, with patient safety leading the way when all aspects of OR materials management is known and followed. We as CS professionals can make dramatic impacts on the overall OR performance when given the opportunity, but we need to know all the steps and how to bring them together.

Tim Brooks is director of surgical services materials management at Yuma Regional Medical Center and has 30 years of management experience. He hosts a Web site devoted to OR materials management and the CSSPD, www.csspdmanager.com. He is a member of IAHCSMM, and also serves as a member of the Infection Control Committee, Hospital VA, Rapid Response, Operating Room Through-put and Lean Six-Sigma Committees.