Instrument Management
Managing the instrument inventory generally is not related to who should be doing rather to who wants to do it. Best practice however may be in allowing Sterile Processing the ability due to the need to have the entire surgical instrument inventory managed by those who handle it the most. Sterile Processing professionals if given the chance can greatly improve the process when all the steps involved are known and followed.
Too often key steps are missing or not even known about due to the process being fragmented between Sterile Processing and the number of users of instrumentation throughout the hospital and surgery.
STEP-1: Sterile Processing must have full control and authorization for the purchasing and operating budgeting of all surgery related instrumentation. In order for effective instrument management to progress your hospital administration must support the centralized approach to managing the inventory. Without the ability to purchase and manage there would be no need to proceed to step two.
STEP-2: Listen to the sterile processing staff, they know better then any manager what's needed and generally know which are used daily.and how many instruments sets are needed to support the OR schedule and room turnover. They can tell which single instruments cause the most interruptions during the day as well as what is needed in your routine back-up instrument inventory.
STEP-3: One of the tools that we have available to Sterile Processing but rarely ever used 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, aide in the reduction of flash sterilization, and improve room utilization. Sterile Processing will need to educate themselves to the OR scheduling process by setting down with the scheduling office staff and find out what takes place and learn how cases are scheduled. Understanding block scheduling and room turnover will also help you improve instrument throughput. Next you need to educate the schedulers to understand how over-booking causes short cuts 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 Sterile Processing or the instrument coordinator for approval. An experienced instrument coordinator will be able to make necessary instruments adjustments to meet demand or make the decision that it cannot be done in the name of patient safety. Included in step three is to build a conflict time for every instrument and piece of equipment in the OR.
Determining instrument and equipment time turnover is separate from room turnover. You may take 25 minutes to turn a room over but for properly disinfection and sterilization of surgical instruments there are a number of varying times. Steam and Sterrad items generally take about the same time from decontamination to sterilization to placing them on the shelf for use; about 3-hours total for one item. This is measuring sterilizer operating times and any manual times associated to one item.
This time is associated to every step in the process, from receiving in decontamination, disassembly, manual washing, sonic, automated washer, cooling, drying, PM testing, assembly, and sterilization; including all the way to putting items back on the shelf for the next case. The problem is that we do not process one item at a time. To insure 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 preventative maintenance (PM) testing is also part of this time and should never be shortened. Special note, Sterile Processing must make sure that PM's are completed on all instrumentation that require it.Simply put, PM testing stops surgeon and staff frustration in the OR.
Time is also associated to the ratio of the number of washers, sterilizers, washer/sterilizer carts, and the instrument inventory, or the lack of. It's not as difficult as it sounds. At an average 350 bed hospital completing 10,000 to 15,000 surgeries per year the total average time is about 4.5 hours; which becomes the equipment conflict assigned to every instrument or instrument set in the OR scheduling systems inventory data base….about 1250 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 Sterile Processing and may have to re-schedule and not over-book.
Before implementing an equipment conflict time you will need to educated 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 staff truly have little knowledge of Sterile Processing problems until we teach them.
Understanding how to use conflict checking is one of the many aspects of Sterile Processing that is overlooked due to our lack of involvement with the OR and the surgical instrument inventory.
Once implemented your processes in Sterile Processing will almost instantly improve. You will find the tray errors and lost instruments will almost completely stop. Sterile Processing staff will be less inclined to take short cuts and surgeon’s complaints will decrease.
STEP-4: Sterile processing 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. If you are using an automated instrument tracking system the description in it must be derived from the OR preference card system….no exceptions.STEP-5: Utilize an instrument count sheet system under the management of one person, generally speaking management. Do not allow everyone access. There are programs out there that are free or can be negotiated for, you just need to ask. 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 or even leased.
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 rooms as well as in Sterile Processing. 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 data-base 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 re-passivation is required due to poor decontamination processes.
Keeping the data-base 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, do not use the instrument manufacturers technical descriptions. Start all descriptions with common nouns, such as, scissor, needleholders, forceps, retractors, and so on.
The proper noun is to follow with type and size as follows, "Scissors Mayo CVD 6.5". Adding the vendor catalog number to the end of the description will also help. Keep a hard master copy with a picture on file along with sterilization instructions in Sterile Processing 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 a lot to consider when moving to a tracking system. Purchasing a tracking system to track single instruments is not a good 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 loosing instruments then stop, 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 the flash sterilization. This means that you need to staff someone on both shifts in the OR to manage the process. Instrument Coordinators that have full control over flash, System-1, and scope management will save your hospital thousands. By having someone in the OR managing the daily instrument needs you will also be able to pin-point where additional sets are needed and address repairs much more accurately.
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 and 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 cost the hospital money and reduces surgeon satisfaction. NOTE: Do not allow you consignment ortho 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 Sterile Processing 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 data-base. 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 Sterile Processing shift change, and again at the end of the day.
I am not talking about hour long reviews: the AM review is completed during the OR shift report looking for add-on cases, the second review is 15-minutes during Sterile Processing shift change, and the third is completed by the night shift Instrument Coordinator before leaving for the day and posted for the AM shift to close out.Note: Knowing what consignment or loaner sets are coming or going is critical to insuring that they are handled in the same manner as any other set before being used on a patient.
STEP-9: Utilize on-site instrument repair services and get to know your repair professional. These people can educate your staff and help you solve all kinds of problems. They can also teach you about repairs and preventative maintenance along with getting you in contact with custom manufacturers that can fix or make just about surgical instrument.
STEP-10: Teach your staff how to do PM's on light cords, rigid scopes, and air powered instrumentsPurchase 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 they shows up on the sterile field. Be proactive and complete preventive maintenance as often as possible.
STEP-11: Do not allow surgeon named trays. The result of allowing surgeon named trays is generally the increase in 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 patient-to-patient. By doing so your hospital is supporting routine use for flash sterilization. This process needs to stop because of the risks to patients, reduced instrument life, poor manual wash, and that it adds time to the daily room turnover.
Routine flash sterilization use is not supported by the AORN, AAMI, ANSI, FDA, CDC, ASHCSP, or IAHCSMM. The focus needs to be on the instrument inventory which if managed correctly will reduce and even eliminate the need for flash sterilization altogether. Standardized your trays and purchase enough so that you surgeons can complete the cases without delay.
The 2007 AORN standards clearly states in recommended Practice IV
“Flash sterilization should be only used in selected clinical situations and in a controlled manner. Use of flash sterilization should be kept to a minimum.
Practice IV – 3: " Flash sterilization may be associated with increased risk of infection to patients because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process. It is essential that all steps in the sterilization process be performed in a conscientious manner."
The steps that are missing from the flash sterilization process is the pre low-level, intermediate-level, and high-level disinfection. Low-level hand washing of an instrument or even complete sets in a sink in the operating room area does not support the necessary steps and or process required to remove microorganisms associated to biofilm that can result in hospital acquired infections.
STEP-12: (which should be included in Step-1), 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 (see attached picture below) then you have a serious breakdown in the washing process. Keeping up with demand is one thing but allowing this to occur indicates a complete lack of instrument management knowledge.
Delays in this area greatly impact the entire process. Questions that need to be addressed
Sterile Processing departments that rely on automated washers to get the job done without utilizing a manual process leading to automation , it’s just not realistic. Washer decontaminators are limited by design. The design benefits can be maximized by the proper positioning of the instruments in the washer. The manual process of opening up instruments and placing them in an orderly up-right position to maximize water impingement needs to be educated and followed.
An analogy for your staff would be to think about your dishwasher at home, are your plates, cups, forks, spoons, and knifes lying down or standing up- Answer= standing up and organized. So, one may ask “Why are we laying them down in automated washers?”
There is a need to not only have a well designed process for surgical instrument disinfection, but there is also the need to develop and/or utilize devices that support instrument washing. The introduction of the 5-inch wide stringer improved the task somewhat, but added additional time to the process in that all ring-handled instruments had to be strung pre-washer.
Some hospitals adapted the use of them…most did not. The wide stringers did help keep ring-handled instruments opened, but they were still laid on each other side-by-side….. thus hindering full water impingement in a washer decontaminator. Time is also added on the clean side to de-string allowing for routine testing of scissors, needleholders…. and then re-stringing to complete the assembly verification of the set.
Recently a new company introduced an instrument cradle that should replace the 5-inch stringer method. Their product called the instrument cradle solves several issues regarding ring-handled instruments. Ring–handled instrumentation is the bulk of any surgical instrument inventory. The cradle utilizes a coil design that separates the instruments allowing for full water/chemical impingement in the washer. It speeds up post-washer cooling, water drainage, instrument lubrication, and allows the sterilization staff to see the instruments much better reducing assembly time. This product will play a major role in the low-level sorting and soaking along with the proper use and penetration of chemical detergents. Lubrication, rinse and dry cycles will also be more complete and thorough.
There are also a number of brushes and hand held water sprayers that aide in the process, but are not utilized at some hospitals due to so called “budget restraints.” Design changes are very much needed for the sink systems in hospitals decontaminations departments. Most, if not all designs, position the sink against a wall and do not give adequate counter space on either side of the sinks. The ergonomics associated to this design do not necessarily attract a desire to work in the area. Standing in front of a sink facing a wall for eight hours is not something everyone wants to do. Changing the design to an island counter in the center of decontamination with triple sinks, additional spray arms, and counter space on both sides of the sinks gives staff a tool that improves their view of the department while allowing better ventilation and lighting.
Decontamination along with conflict checking of instruments are the two most important aspect of the surgical materials management instrument throughput.
