Design your preventive measures around training, accountability and maintenance protocols that include a formalized system for tracking and trending of repairs. These fundamentals will arm you with the knowledge necessary to make effective strategic financial, operational and clinical decisions for your department.

The Multi-society guideline for reprocessing flexible gastrointestinal endoscopes recommends device-specific reprocessing instructions and regular competency testing for all personnel involved in endoscope reprocessing.1 Adhering to these evidence-based guidelines will help your facility prevent infection and maintain an inventory of properly working equipment and scopes available to start procedures on time, every time. Procedure start-related delays escalate into scheduling set backs as well as staff overtime and physician dissatisfaction.

Reprocessing: Your facility should have a formalized, competency-based reprocessing training plan in place, which includes regularly scheduled in-services. Make sure education conforms to the instructions of the original equipment manufacturer (OEM). Also work with your infection control and risk management departments to ensure consistency between your facility’s reprocessing policies, procedures and protocols, OEM instructions, applicable state and federal regulations, and accreditation requirements outlined by organizations such as The Joint Commission and the Accreditation Association for Ambulatory Health Care (AAAHC).

Handling: Training should also include safe handling protocols in order to avoid inadvertent and unnecessary damage to the scope’s interior and/or exterior. Inspect the reprocessing area to ensure it remains free of sharp edges or objects; do not transport, reprocess or store supplies and/or accessories with flexible endoscopes at any time; and avoid stacking scopes in transport containers, on countertops, and in sinks.

Resources: Look to your OEM for instructional materials, such as reprocessing manuals, guidelines, checklists, wall charts and training videos. Some OEMs also offer assistance from on-site endoscopy support specialists or consultants and provide hands-on and online scope care and maintenance education as well. For quick links to reprocessing and cleaning, disinfection and sterilization (CDS) information, including the Multi-society guideline for reprocessing flexible gastrointestinal endoscopes, visit www.olympusamerica.com/cds.

Encourage staff accountability for the quality of your reprocessing by helping them understand the direct correlation between proper endoscope care and handling and the safety of your operation. They must comprehend that skipping or ineffectively performing reprocessing steps or failing to follow OEM instructions can adversely affect patient safety and increase the incidence of repair.

For example, staff can avoid undue chemical damage to the scope as well as cross-contamination risks by adhering to the detergent and/or disinfectant/sterilant OEM’s instructions for reprocessing times, temperatures, dilution, shelf life and expiration.

Ownership: Your entire staff should actively participate in repair reduction efforts and take responsibility for their part in the process. To increase your unit’s efficiency, however, consider delegating the responsibility for your overall repair reduction program to a single staff member. This individual can monitor the big picture, track and trend repairs and look for opportunities to reduce their occurrence.

Resources: For more information on safe handling,
reprocessing and disinfectant/sterilant guidelines, visit www.sgna.org/Resources/standards.cfm, www.olympusamerica.com/cds 
and www.olympusamerica.com/endoscopecare.

Since repair frequency and expense can quickly erode overall procedural efficiency and projected budget, daily and periodic maintenance go a long way in your repair prevention efforts. In addition, schedule regular equipment evaluations to help detect potential problems before they escalate into major repairs.

Endoscope evaluation: Prior to each procedure, proac-tively inspect and test endoscope functions such as air/water, suction channel and image. This helps ensure a patient-ready endoscope and may significantly reduce repairs by catching damage early on. Examine the insertion tube and bending section for cuts, holes and dents. To avoid fluid-invasion damage, regularly check watertight caps for wear and tear. If in doubt, remove the scope from service and leak test it prior to continued use.

Resources: Consider using a monthly equipment check sheet (See Example G). The inspection takes only a few minutes but could significantly reduce and/or prevent the frequency, extent and cost of repairs.

Consistent tracking of the type, cost and frequency of repair expenditures proactively facilitates training focused on issues specific to each institution or center. It also provides benchmarks for measuring overall repair reduction efforts.

Develop a cache of tracking tools to help you monitor your endoscope repairs by procedure type, scope model, individual scope and scope handler. Your tool chest should include inventory lists, repair and usage logs, repair cost-per-procedure information, and monthly equipment and post-repair checks.

Inventory lists: (See Example A) Monitor the size and age of your resource pool and appropriately balance your scope inventory against your procedural requirements. You can expand your list to include video processors, monitors and/or other equipment. Knowing the date of purchase and the age of the instrument will assist you when comparing annual repair costs.

Utilization worksheets: (See Example B) Track the use of each individual endoscope to determine its utilization rate. Comparing usage log information with repair log data often tells the story of a workhorse scope inventory that no longer reflects physician preference or procedure mix.

Repair logs: (See Example C) Repair details enable you to analyze repair frequency by individual scope, repair cause, findings and cost. Using one worksheet per individual endoscope allows you to trend care, handling and repair costs, frequency and repair duplications. Paying close attention to these details can help you identify troublesome scopes or problem staff. You can then direct your repair reduction efforts, staff and in-service trainings to areas where they will have the greatest financial impact.

Repair trends: (See Example D) Repair frequency worksheets provide invaluable assistance in identifying repair trends over time. Determining the occurrence of specific types of repairs allows you to identify problem areas and design process improvements to reduce the incidence of those repairs. For instance, in Example D, repairs were tracked over a year. By comparing the first half of the year with the second half, we can see there was a reduction trend in the repair numbers by repair type during the second half (July-December) of the year.

Cost calculations: (See Examples E and F) A yearly repair expenditure chart breaks down and compares overall repair costs by type of scope and procedural volumes. It paints a more concise picture of repair hot spots that require further investigation. In Example F, EGDs accounted for 21 percent of the facility’s total procedural volume, with repairs on gastroscopes requiring 9.64 percent of the total repair expenditures. Conversely, sigmoidoscopy totaled just 3 percent of the total volume, yet repair expenditures on these scopes accounted for 7.54 percent of the total repair dollars. Colonoscope repairs accounted for 82.82 percent of total repairs.

At first glance, this expense may seem consistent with the high colonoscopy volume. However, upon further examination, the repair cost may also reflect poor handling resulting from rushed reprocessing to ensure available workhorse endoscopes. Referencing this facility’s utilization log (See Example B), we can see that only 6 colonoscopes (37.5 percent of their total scope inventory) were used to perform the majority (82.2 percent) of the facility’s total procedure volume.

This type of cross-referencing between tracking logs helps to more precisely investigate problem endoscopes. For instance, in Example C repair expenditures on A-Colonoscope, serial no. 12345 totaled $23,400 or 25.8 percent of this facility’s annual colonoscope repair expenditures ($90,641) and 21.4 percent of their annual total repair dollars ($109,438). You can further quantify this assumption by documenting the number of procedure-start delays related to lack of an available endoscope, held up in reprocessing or out for repairs.

Set a goal to reduce endoscope repair cost-per-procedure expenditures to achieve a desired internal or external benchmark. For instance, our sample facility (an endoscopic ambulatory surgery center/EASC) might set a goal to meet the 2007 repair cost-per-case benchmark data collected by Olympus for peer EASC facilities. To do so, they would need to reduce their overall repair cost-per-case by $3.39. Dropping repair costs from $13.88 to $10.49 per case would save this facility $26,737 annually ($3.39 x 7887 cases).

Equipment check sheets: (See Examples G and H) Repair costs can quickly degrade overall procedural efficiency. Use monthly equipment check sheets and endoscope post-repair checklists to record periodic checks of your equipment.

Develop long-term cost containment plans to augment short-term repair reduction efforts.

Strategic business plans: Start with a strategic business plan that addresses inventory needs for today, and three to five years down the road. The plan should include:

• Forecasted procedure volume and mix. This will help project an adequate scope inventory.

• The size and age of your equipment resource pool. This is critical to effectively plan for replacing obsolete and worn equipment.

• Endoscope repair histories by model and serial number. Some OEMs can provide medical device histories for endoscopes repaired through their facilities.

• The number and frequency of procedure-start delays and cancellations resulting from unavailable equipment. This will provide a good indicator whether your inventory sufficiently meets your typical procedural load.

• The cost of procedure-start delays and cancellations (i.e., idle staff time x salary dollars per procedure). Weigh this number against the expenditures for additional equipment to evaluate your best options.

Your plan must also anticipate the number of automated endoscope reprocessors (AERs) and associated chemicals you use to reprocess greater volumes of endoscopes. It does not matter how many scopes you have if you cannot get them in and out of the AERs in a timely manner. Rushing to load and unload an AER can lead to unnecessary repairs as well as staff overtime required to reprocess scopes at the end of the day.

Sources:
Am J Infect Control 2003; 31:309-15.