Where are My Instruments and Sterile Supplies?

By Tim Brooks

As sterile processing department (SPD) professionals, the questions often heard asked by surgeons, nurses and scrub techs are: “Where are my instruments?” or “Where are my supplies?” These two questions are usually asked when patients are already in the operating room (OR) suite prepped for a lifesaving procedure, when at this point any significant delay could result in infection or death. Occasionally the answer is “I don’t know,” which escalates the situation, resulting in high levels of anxiety for all parties involved. Unfortunately for SPD providers, during a busy day the answer is true, they simply do not know. When the search begins it can be hampered by numerous conversations and phone calls followed by panic for reasons which the OR has little understanding. 

However, these are valid questions asked of sterile processing departments, and “I don’t know” can be replaced with “It’s on the way” when all perioperative employees participate in the management of these two vital inventories; neither one more important than the other. OR caregivers generally are unaware of the daily, more like hourly, management and processing of thousands of instruments and supplies. Both are in movement from the moment a patient(s) is scheduled for procedures. SPD must consistently work to balance the OR schedule addressing, add-ons, traumas, transplants, cancellations, TBAs and re-schedules. These changes cause both inventories to circulate in constant motion throughout the OR on any given day. Stock levels for both can be set to address just about any situation; however, they must meet unpredictable demands. If someone could determine how many patients and what their needs are on a given day there would be no need to answer the questions posed.     

Additionally, sterile disposable supplies and surgical instrument sets inventories require two very different management processes. Add low inventory levels of either one, lack of storage space, poor post-op instrument return process, along with overbooking sets and frequent schedule changes the question of where are they gets difficult to answer even with the best systems in place. More often in today’s hospitals, SPD is managing both instruments and supplies, increasing the stress on the case-cart process and daily schedule. The reaction is two-fold, sterile supplies receive comparable questions, although they experience limited movement. Surgical instruments, however, are in motion during a day requiring reprocessing and quality assurance not seen with disposable supplies.

Sterile supplies have had the support of computerized materials management systems for years, allowing for historical tracking to be able to adjust inventories and set par levels. Surgical instrument management systems are still in their infancy, rarely interfaced with the OR schedule. In hospitals throughout the United States and around the world, SPD departments lack the basic computer systems needed to manage one of the most difficult re-usable and expensive inventories in a hospital.

Lack of an instrument-management computer program, along with overbooking of surgical instrumentation results in the perception that SPD has no desire to answer the questions “Where are my instruments?” or “Where are my supplies?” In most cases they have no ability to do this due to the lack of support for the department and understanding of the instrument process. For SPD the answer is education, and accepting responsibility regardless of how they manage the inventories. They must have a ready answer to those questions at any time. OR leadership, surgeons and staff, along with infection prevention, risk management and hospital administrators, need to be educated to the management and complexity of processing thousands of instruments and supplies daily -- all of which are attached to preference cards in a system separate from SPD supporting the largest revenue service for hospitals.

In any given hospital there will be a materials management (MM) computer system and an OR scheduling system; maybe an instrument management system. Neither the MM nor the OR systems will be interfaced to the surgical instrument inventory computer system, that is if your hospitals SPD department is lucky enough to have one. The latest electronic medical record systems (EMR) miss the boat as well.

So how do we stay focused and get this all done? By knowing what we do, where to look, how to get support, and from whom to get it. First, SPD needs to educate to the management of the two inventories in order to gain support. Disposable sterile supplies are easier to address due to the two computer systems supporting them and the data generated. Basic knowledge of par levels and order process take little time to articulate and can best be illustrated with a simple flow chart.

The daily cycle for disposable sterile supplies is as follows; ideally the product is on a shelf at a manageable par level in one storage location near the OR. This is rarely ever the case, resulting in at least three storage locations, SPD case cart support area, OR central core, and/or Central Supply.  The flow on the chart (see the August print issue of ICT for the chart) addresses a simple process as it is.  For the most part it is the daily path and should be managed by a staff with different skill sets. The larger the hospital and more expanded service line the higher the number of line items managed. The process remains the same.          
 
Now let’s look at surgical instruments. A very different flow process arises with higher tracking requirements along with quality assurance measures experienced with sterile disposable supplies before they ever arrive on the shelf. Logistics gets even more complicated as hospitals grow adding more operating rooms and increased volume with expanded service lines but no production expansion space for SPD let alone storage space. If the hospital’s SPD does not have an instrument management system, it has little ability to track vital usage supporting the purchase of additional instrumentation. Poor block scheduling, along with overbooking instrument sets, forces SPD to complete fast-turn and immediate-use processing, often skipping vital quality assurance steps for the sake of keeping up with the schedule -- this in place of managing the instruments to meet higher quality assurance.

The results are higher infection potential and delays to the OR schedule. An OR operating cost per minute will give you a very quick look at how costly delays are. However, there is no set expense for surgical site infections. Just one infection can cost more than an instrument management system including the annual service agreement and interface to the scheduling system for years. Having the ability to track instruments and quality assurance helps SPD answer the question.      

SPD has come under more scrutiny due to dirty instruments found in sterilized sets at the time of use. Fast turn-around and immediate-use sterilization does not provide an equal standard of care for surgical instruments that are properly cleaned, decontaminated, reviewed for QA and sterilized.

The development of the instrument management computer system provides long-overdue tracking data to support what SPD must accomplish. Quality assurance within these management systems supports an even higher level of surgeon satisfaction and positive patient outcomes.

The surgical instrument chart illustrates the flow for only 21 routine locations, leaving an additional 25 not discussed. The challenge now is for you to educate to the chart and add or subtract steps as they relate to the hospital you serve. Then to educate your surgeons and hospital leadership in all related areas. Lastly, there are seven more inventories supporting instrument management, number of case carts, supply bins on case carts, instrument washer including sonic and scope processors, steam sterilizers, loading and transfer carts, VHP sterilizers and most importantly trained certified staff.

Examples; optional
1. Ideally - On the shelf ready for use
2. On the case cart ready for procedure
3. In an elevator or dumbwaiter headed to the OR
4. On the case cart for the next procedure
5. On the back table in the OR
6. Back on the cart pending transport out of the OR room
7. On the cart in transport
8. In an elevator or dumbwaiter
9. On the case cart in decontamination
10. On a cart staged for priority in decontamination 
11. In a sink receiving stage-one cleaning of gross contaminates
12. On a washer rack waiting for additional sets to complete a full washer load
13. In a washer receiving high level disinfection
14. On the washer rack cooling in the assembly room
15. On a shelf staged for assembly
16. On an work station being reviewed for QA
17. On a shelf staging for missing instruments
18. On the work station with assembly in progress
19. On a shelf staged for sterilization method
20. On a sterilizer cart pending full load
21. In a sterilizer completing high level sterilization
22. On a sterilizer cart cooling
23. On the shelf in SPD storage area
24. On the shelf in the OR core
25. On a cart ready for On-site instrument repair
26. In a truck receiving on-site repair
27. At an in-service in the OR
28. Setting on a cart that someone forgot to send back to SPD
29. At an in-service in SPD
30. In the trash somewhere in the system
31. In a sterilizer in the OR
32. In the Emergency Room in use
33. In the Emergency Room unknown by SPD
34. In the ICU in use
35. In the ICU unknown to SPD
36. On a trauma cart
37. Put in the wrong storage location
38. On the shelf with the wrong label
39. In the OR educators office
40. In the OR directors office
41. Loaned to another hospital
42. Loaned to your out-patient surgery center the day of surgery
43. On a TBA cart pending OR schedule
44. On a returned, not used cart in the OR
45. On a returned, not used cart in SPD
46. In the OR buyers office pending the receiving of missing instruments

Tim Brooks is the manager for the sterile processing department (SPD) at the University of Arizona Medical Center. He has 37 years of management experience, 27 years in hospital SPD and OR materials management. He holds a BS in business management and CBSPD manager certification. He hosts a non-profit website devoted to SPD and OR materials management, www.csspdmanager.com. He is a member of IAHCSMM, and also serves as a member of the hospitals Infection Control Committee, Operating Room Product Evaluation Committee, and Perioperative Services Executive Committee. Additionally, he serves on the STERIS 2014-2015 Sterile Processing Advisory Committee. Brooks has written a number of published articles and completed public speaking on topics related to the management of surgical instrumentation.