by Jim Heller, ST
Egleston Children’s Hospital, a 235-bed pediatric teaching facility that is part of the Emory University Hospital System (Atlanta, GA), demands the very best in the critical care of its young patients. In support of that care, the team in the Central Processing (CP) unit must deliver to the hospital’s surgeons the finest, precision-tested surgical instruments available. Excellence has come to be expected as a CP routine operating procedure by their partners in the OR. The CP department has earned that reputation through careful management control of instruments, from choosing an instrument repair service partner to labeling and tracking instruments.
Egleston’s CP department has made remarkable progress in improving surgical instrument repair over the last five years. When I first arrived as the new director of Sterile Processing (SP) in 1992, our department assumed the challenge to turn the existing department into a state-of-the-art, high-tech unit that would earn the respect of our customers. In Egleston’s 10 operating rooms, nearly 11,000 pediatric surgical procedures are performed annually—everything from general to open heart surgery. Obviously, this surgical volume requires the maintenance and management of a large volume of specialized instruments.
On first inspection, we confirmed that we were low on instruments and that those we had were in need of refurbishing. We made it a short-term goal to inventory enough instruments to see us through just one day of cases. Consequently, we now have over 66,000 instruments available (up from around 25,000) for 248 different types of trays.
Because we had made such a major investment, we wanted to preserve our new assets for as long as possible. As a result, two new challenges unfolded. One was to ensure that every instrument was maintained in top working condition. The other was to form a plan to track each item in the inventory. Teamwork was crucial to the department’s success.
Finding a repair service
We are strong believers in preventive maintenance. After all, no one wants to be responsible when the surgeon discovers a malfunctioning instrument in the tray at a critical moment. We continually educate our technicians on the art and science of instrument inspection. The SP chose to work in close partnership with our instrument repair vendor to help us identify compromised instruments and bring a new perspective to the department. Part of the vendor’s livelihood would depend on educating our staff to recognize flaws in instruments.
However, after interviewing a multitude of repair companies, we concluded that although the market was awash in vendors, there are only a few real professionals. Since we were about to entrust the care of thousands of dollars worth of equipment to one repair firm, it must measure up to the standards we set for our department. Therefore, we treated the selection of a vendor with the importance normally given when making a hiring decision. Our decision-making process ultimately led us to select an instrument care vendor who could meet our extensive needs.
The department had problems with some manufacturers’ repair programs in the past because their onsite technicians would routinely charge for every item on a tray regardless of whether it needed attention. Furthermore, their “non-repairable” rate was suspiciously high, and the service vendor urged the hospital to order replacements from them for instruments we suspected still had a lot of usage left. Also, some manufacturers refused to adapt an instrument to a particular surgeon’s request, advising us to order a high-dollar “custom” piece instead. As a result, we didn’t feel that an original equipment manufacturer (OEM) offering both instruments and repair service could give us unbiased service.
Meanwhile, it seemed that there were many local independent repair services, as well as a number of “brokers” and other mail-in services vying for the opportunity to serve us. We contacted over 10 local repair services, brokers, and other mail-in services, interviewing each one to see if they could meet our needs. However, we were demanding of those we would trust with Egleston’s instruments. Whenever we questioned their training background or efforts at updated training, we never received satisfactory answers. Many seemed to be learning as they performed the repair job. Even if skills seemed acceptable, many were eliminated as candidates because they could not provide proof of liability insurance.
A relatively new breed of medical equipment repair company is called a “broker.” Brokers are middlemen who pick up items for repair, forward them to a free-standing repair facility, and return repaired instruments back to the hospital. We could send instruments to the same repair facility and pay a lower price because then we wouldn’t be paying a commission to the broker who may know little about surgical equipment and repairs. The time saved contacting a variety of repair companies is not worth the extra commission it costs.
Our surgical instruments and equipment make up a most valuable asset. Central Processing would not entrust them to someone who makes all the right claims, but can’t back them with legitimate service. There’s an outgrowth of so-called mail-in independents, but they are usually under-capitalized and often “here today, gone tomorrow.” And there are too many possibilities for damaging delicate instruments, especially lumened scopes.
It’s important to know exactly who is handling the instruments and other equipment. Ideally, there should be face-to-face accountability with the technician and the convenience of a mobile same-day-service right at the hospital. However, to ensure excellent repairs and honest advice about the replacement, the repair technician should operate as an arm of a national organization with a reputation for quality. We need the support and assurance of a major repair facility behind the technician. Price is a major consideration as well.
In my previous CSP management experience at a Midwest hospital with 17 operating rooms, I had already faced many of the same dilemmas relative to instrument care. In this hospital, we had received good service with one repair firm (Mobile Instrument Service of Bellefontaine, OH) that used a mobile instrument technician. We evaluated this option as well. We ultimately opted to use this same company’s Atlanta counterpart to become a part of our surgical instrument processing team. The firm isn’t an OEM, and offers an extensive array of repair services onsite, meaning I didn’t have to artificially inflate our inventory to allow for in transit repairs. As a mobile service, operating out of their own repair van, we would not need to supply working space, specialty sharpening equipment, or microscopes. Furthermore, they could be called as needed or used routinely. They provide consulting, technical advice, and inservice support, while we continue to maintain control over the destiny of every instrument.
After making a conscientious effort at preventive maintenance, our replacement rate due to damage sank from a high of 50% to under 10%. Since surgical instrument prices have risen faster than almost any other category of hospital supplies, our repair program has had a significant impact on the replacement budget, simply because our damaged instrument recovery capability has increased.
Marking and tracking instruments
However, capitalizing on the expertise of a repair service can only become efficient when one’s instrument inventory is catalogued in some fashion, with each instrument and tray identified for tracking and sorting. This was the second step toward our goal of organizing the department, especially with the increased amount of instruments we now had on hand.
We set up a manual system wherein we listed all of our sets and then had each tray and each item on that tray permanently color-coded with Dura-Bond. We then had to determine a usage frequency for each set. After tracking that for a period of time, we were able to predict our maintenance and repair needs regularly. For example, we now can pull and service the needleholders and scissors before they become ineffective.
Armed with instrument usage data, our technicians have become very proficient at taking sets down on a pre-determined basis to inspect for faults. Trays used daily need to be examined at least quarterly, while those that are not used as often can be inspected every six months or even annually. Furthermore, we count on our surgical instrument repair specialist to help us by identifying cracked box locks and bent, twisted, or mis-aligned instruments on a routine basis. These items are then serviced before they cause complaint, which improves our customer satisfaction. Since the instrument repair company only charges for repairs on instruments that are damaged, we don’t worry about paying for an entire tray when it’s rarely, if ever, necessary To prevent harboring infectious pathogens, a repair expert must be equipped to identify potentially hazardous conditions on instrument surfaces. These areas can be microscopically investigated at locations where a coated or insulated instrument has become compromised due to minuscule cracks and crevices. Due to the small size of virus or bacteria, minute instrument imperfections can introduce the possibility of cross-contamination from rigid scopes that have a damaged distal end or flexible scopes with a small hole in the outer sheath.
To be a completely well-rounded program, all inspection and repair information must be recorded. Since the instruments are color-coded, keeping maintenance logs is really a fundamental feature of the process. A professional repair service will help with the effort.
As an upgrade to our current program, we recently instituted a laser-etched bar coding system wherein each instrument is marked for computer scanning before it is packed into the tray. This labeling system has enhanced our repair tracking considerably. For example, we can set the computer up to identify a particular instrument after every 25 uses to alert us to inspect it more carefully for wear. If a defect is found, the instrument can then be set aside for repairs from our mobile service technician. Electronically monitoring the life of an instrument or other OR equipment will leave little margin for error about when repair decisions should be made. So far, the system has confirmed most of what we had been doing manually. However, we look for even more savings in the future.
Though we’ve made an array of advances and upgrades in the last three years, our surgical instrument management and maintenance system was the foundation on which we built other improvements. There may be some Central Sterile department managers at other hospitals who underestimate the importance of keeping their instruments in top working condition. But this encourages functioning in a crisis management mode when the need for a particular instrument becomes critical. A lack of preventive maintenance can lead to frequent instrument repairs or shortening the life of an instrument due to excessive cumulative damage and wear. To avoid either costly or inefficient management scenarios, we can maximize the life of instruments and keep the OR staff happy by regular tracking and preventive maintenance.
The training and background of the surgical instrument repair source can promote excellence in a CS department. Simply hiring a tech or two and having brought the repairs made in-house would not yield the benefits of a large professional company’s ongoing research and development. Nor would we have the access to replacement parts available to a national firm with their volume purchasing discounts. Hospitals need not get into the repair business.
Another alternative we once considered was the use of disposables. However, we simply would not provide our doctors and nurses with lesser-grade instruments. Because disposables may damage other instruments in the same sterilizer load. Electrolytic action lifts carbon particles from the exposed metal of low quality plated disposable instruments and deposits them on the stainless steel surfaces of high quality ones, causing oxidation and, ultimately, rust. Disposables represent an excess that we can live without
As a staff, we feel proud of our accomplishments, especially since our customer satisfaction quotient has so significantly increased. Furthermore, Egleston’s Children’s Hospital was recently named one of the Top 10 Children’s Hospitals in the US by Child magazine, and our department feels like we have every right to share in that honor.
In the last 15 months, we have proudly played host to Central Sterile and/or OR personnel from over 190 different hospitals who have come to tour our facility. They have traveled from as far as Australia, Canada, Italy, Sweden, Germany, and all points across the US to learn from our experiences. It’s certainly not within every Central Service department’s budget to install a computerized bar coding system. However, it is within the reach of every manager to benefit from a concentrated preventive maintenance effort, because it will save money in the long run. The key is knowing the background, training, and skills of your repair technician, and then making her or him a part of your processing team. It’s a common-sense solution that is all too uncommon.
Jim Heller, ST, is the central processing manager at Egleston Children’s Hospital at Emory University (Atlanta, GA).
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*Reprinted with permissions from Infection Control & Sterilization Technology February 1996, Vol.2, No. 2, Copyright 1996, Mayworn Associates Inc., 507 N. Milwaukee Ave., Libertyville, IL 60048 (847) 680-7878