The Tools of the Trade

When it comes to surgical procedures, the instrumentation used is just as crucial as the surgeon and staff performing the procedure. But just as important is being able to use the right piece of equipment and having it available, is maintaining the balance of creating a healthy, sterile environment for the patient, all while pumping up your bottom line. So how do ambulatory surgery centers keep up with the latest instruments and stay within their means financially?

Cost containment

Surgical instrument costs have been on the rise and with the addition of new and improved instruments, it makes that much harder to keep costs down. “Cost containment is absolutely essential,” says Nancy Chobin, RN, ACSP, CSPDM, sterile processing educator/consultant for St. Barnabas Health System. “Everything goes up with cost of living, but when you consider the sophistication of the instrumentation we’re using today, these are devices that can cost anywhere from $5,000 to $38,000.”

Another factor to figure in is the role of Medicare, says Tim Brooks, director, surgical services materials manager and CSSPD at Yuma Regional Medical Center in Yuma, Ariz. “Medicare has changed a lot over the years. You used to get credit for just about everything that you bought through capital. Well that doesn’t happen anymore. (Now) you have to pay a lot of attention as to what you’re buying and how you’re going to use it.”

Loss and Damage

Another aspect for cost containment is the damage and even loss of these vital tools. “There really needs to be a system of accountability for everyone who touches the instrument,” Chobin says. “And when you have that accountability, you can identify who’s damaging it and who’s losing it. Not for finger pointing, but for problem resolution and that’s really important.”

Without this accountability, instruments can be lost and damaged, opening the ASC to disburse literally hundreds of thousands of dollars a year to replace or repair them. One of the ways to alleviate this is keeping count of instruments before and after a surgical procedure, a practice endorsed for many years by the Association of periOperative Registered Nurses (AORN). “Unfortunately, in many facilities today, because of lack of time, there are many operating rooms that will only count instruments at the end of the case, if the instrument can be left in the patient,” Chobin states.

“My philosophy is if I lose it in my department, I’m 100 percent responsible and I will pay to replace it,” she adds, also pointing out how important communication between the entire staff is during a procedure. “...If I don’t even know that you sent it back to me, then I’m paying for something (I didn’t lose) and we’re never going to solve the issue.”

Instrument damage also plays a role. To avoid using them during a procedure, the Association for the Advancement of Medical Instrumentation (AAMI) recommends that all instruments be inspected through a lighted magnifying glass. This helps for several reasons, “We very rarely have light where we need it; it affords the preparer the opportunity to see defects that might be missed with the naked eye; and very often, we have to look at the catalog number on the instrument,” says Chobin.

But all instruments should be tested as well. “For example, in our healthcare system, the scissors must be tested every time,” Chobin notes. “It is completely unacceptable to send a scissor to the OR that doesn’t cut. As wonderful as our surgeons are, they can’t cut unless they have a pair of scissors that work.”

Managing instruments

For Brooks, the predicament with instruments at Yuma Regional Medical Center was simply a lack of them bought by surgeons to use. The instruments then were overprocessed from the high volume of usage in order to fit a surgeons’ block of scheduling. “And that results in more repair costs, more replacement costs and the expenses just continue to grow from there,” he says. “You have to have multiple sets (of surgical instruments available), and you have to buy enough to meet the demand of the surgeries that are being performed in your facility, without causing delays to scheduling and keeping everybody happy at the same time.”

To resolve this, Brooks and his staff were given a chance to manage the instrumentation proactively. “We monitor the OR schedule and we manage based off of what’s actually taking place, rather than gut feelings,” he states. Instrument purchasing is strictly done through his department, but he also has instrument coordinators working in the OR keeping a close eye on all of the cases for the day. “They know every single surgery that’s going on, every single piece of equipment, every instrument that’s being used,” Brooks notes. “They have the determination as to whether they can or cannot keep up with the schedule.” Conflicts are brought up to the coordinators, not only to avoid scheduling issues, but also to determine if more instruments are necessary.

Brooks also takes the time to explain to his operating room staff how much time is needed to process an instrument for the next procedure, and emphasize the need for multiple sets. “If it takes four hours to process a set and each case is two hours long, and you want to book back-to-back cases, we can’t do it with just one set.”

Flash Sterilization

A lack of instrumentation leaves the staff, in many cases rushing to process them, more often than not relying on flash sterilization — a practice that has become common to many ASCs. “Flash sterilization was designed for instances where you dropped something and you need to get it back, and everything else is tied up,” says Brooks. “It was never intended to be routine. A lot of ASCs have a tendency to flash everything between cases, because they simply don’t have enough instrumentation.”

But the practice not only could damage instruments after overusage, but flash sterilization could impact the safety of the patients involved. “The thing about flash sterilization is if you take an entire instrument set and you try to hand wash it in a sink or anywhere in the OR, you are not going to successfully disinfect it.” says Brooks. “And if you can’t successfully disinfect it, then you can’t successfully sterilize it.” The AORN has also come out in recent months against flash sterilization, stating it is not recommended to be part of a typical OR routine.

“We’re providing two standards of care, and that’s unfortunate,” Chobin remarks. “For example, the 7:30 a.m. patient gets a wrapped set (for a procedure). The likelihood is it will be flashed (afterward) and that’s unacceptable. Why should the second or third patient of the day have a lesser standard of care than the first patient?”

Education

A vital part of cost containment for surgical instruments is education and it starts at the top, according to Brooks. “It starts with the surgeons. When you start educating them and explaining to them — whether they are new and they’re going to start doing procedures, or they’re already existing and are doing a new procedure that requires additional instrumentation — if you explain to them that it takes us this long to process this particular instrument set, the light bulbs start going off in their heads.”

But it’s also important to keep in mind to educate the rest of the staff as well. “Instrumentation has to be handled by multiple people, so you have to educate everybody on every single step,” Brooks points out. “Everybody has to understand that instrumentation requires specific steps, specific handling.”

No more is this crucial than introducing a new instrument. The lines of communication need to be open between the staff. “Our policy is if you’re considering bringing something in, before you even buy it, we want to see the manufacturer’s instructions,” Chobin says. “For example, I was at one of our facilities and they brought in a litho crusher handle. This required about a 10-step process for cleaning, and if you weren’t aware of a certain little latch on it that had to be off in order to pull a cartridge out in order to properly clean it. If somebody didn’t do that, they could’ve stripped the cartridge.”