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But there’s still room for improvement, sources say

It’s a scenario that most CS and OR staffers have experienced firsthand at least once (but likely dozens — or more – times) in their careers. The good news is it’s one that is also becoming less common as more healthcare organizations embrace proactive instrument maintenance.

"As the industry continues to mature, I feel very positive that healthcare facilities are taking advantage of the value offered by well managed instrument maintenance programs," noted Alex Vrancich, vice president and general manager of Spectrum Surgical Instruments Corp., Stow, OH.

Despite Vrancich’s optimism, even he pointed out there’s still room for improvement. It’s an observation shared by a number of other industry insiders. As Susan Williams, marketing manager of Cardinal Health’s OnSite Services, explained, in theory, many healthcare organizations understand the importance of instrument maintenance. "However, in application, instrument maintenance programs sometimes fall to the wayside of day to day ‘fire fighting.’"

Failure to adopt and effectively implement a proactive instrument maintenance program – that is, one that focuses on preventive maintenance — poses problems on numerous fronts. Not only does it lead to surgeon dissatisfaction (as well as that of many other healthcare workers who manage or use the devices), it can increase patient safety risks. Aside from that, it can also cost hospitals a bundle by delaying surgical cases, wasting valuable time by forcing CS staff to stop what they’re doing to hunt down replacement devices, and increasing the need for premature replacement of instruments that could have been easily and cost-effectively maintained through proper rotation and a proactive preventive maintenance program.

"Many facilities don’t have a plan in place for routine maintenance to prevent minor problems from becoming major ones that will lead to premature replacement," confirmed Robert Purtell, director of business development for Bellefontaine, OH-based Mobile Instrument Service & Repair.

Proper endoscope handling and inspection can help to avoid and catch early damage of medical instrumentation.

If failure to implement a sound preventive instrument maintenance program incites so many problems then one could understandably question why some facilities are still lagging behind in their efforts.

Experts contend that many factors are to blame, with capital outlay being a primary one. Ironically, that becomes one of the most costly mistakes a facility can make, according to Vrancich.

"The main reason facilities don’t employ preventive maintenance programs is that they must spend money upfront," he said, noting that, as a result, facilities have opted to work in a reactionary mode, where they fix devices when they break, rather than placing instruments and equipment on a preventive maintenance schedule that can prevent the damage altogether.

Too few instruments sets that force staff to use and reprocess the same instruments over and over is another common problem, as is the somewhat common perception that waiting to service instruments and equipment will generate savings.

"Extending the period of time between services is neutralized by creating an extensive repair to those instruments, or generating a premature replacement as a result of creating additional damage to an instrument that already is in disrepair, instead of performing service on an ongoing basis when the costs are more manageable," said Frank Mohacsi, vice president of sales, InstruMedics LLC, Teleflex Medical.

As sterile reprocessing manager David Narance, RN, BSN, CRCST, of MedCentral Health System in Mansfield, OH, explained, facilities must look past the initial cost associated with implementing a preventive maintenance program and recognize that the efforts will pay big dividends quite quickly.

"It really is a classic case of it takes money to save money," he said. "When you see the big picture it becomes clear that [preventive instrument maintenance] is money well spent."

Narance should know. As a former operating room nurse-turned SPD manager, he’s seen the impact of damaged or poorly maintained instruments from both sides. In the sterile reprocessing department he recalled how – prior to the implementation of a good preventive instrument maintenance program — he and his staff would field complaints about instruments from surgical staff and have to frequently contend with broken, misaligned and otherwise poorly maintained devices that wound up being tagged for repair. Rather than stick with the highly inefficient and costly approach of repairing devices in a reactive mode, the facility, under Narance’s direction, adopted a proactive maintenance program. These days, frequently broken down instruments and reactive problem-solving are a thing of the past at MedCentral.

"We have invested a great deal in our preventive maintenance program, but the savings we’ve been able to realize have [far surpassed] any money we’ve spent to keep our instruments in good working order," said Narance.

Techs learn proper instrument taping at Spectrum Surgical’s Instrument University workshop

Not surprisingly, instrument mishandling plays a big role in costly repairs. Much of that can be chalked up to the very nature of healthcare that requires many different hands to come in direct contact with instruments on a daily basis.

"When you have so many people who handle the equipment on a day-in, day-out basis, damage can occur at any point during that daily use cycle," noted Gregg Agoston, associate director, KARL STORZ Services, Culver City, CA. He explained that when one looks at the number of hands that touch a laparascope during a typical day, for example, it can start out with one person in the CS department, be transported by another, then set up in the room by the nurse and then handled by the physician. From there, it can potentially be removed from the room by yet another handler, then taken by the decontamination person before it goes back to CS for reprocessing.

"It then goes to be sterilized and is taken out of the sterilizer by another person before it is put back on the shelf," Agoston continued. "So that adds up to eight people who handled that laparoscope in just one use. And damage can occur at any point in that cycle."

Time constraints that put pressure on staff to transport and process devices quickly further ups the odds for damage, particularly with delicate items that may get mishandled along the way. As Agoston explained, devices may be combined with other instruments in the decontamination department, with fragile or delicate items being placed directly on top of one another, or sharp instruments being placed in contact with items that can be easily damaged by them, such as cables and cords.

"It’s just the nature of trying to save time in turning the equipment around and reprocess it. But those short cuts often cost the hospital more money, particularly when you’re talking about endoscopes or items that have cables, such as cameras or other delicate instruments," he said. "Without proper care and handling by staff and surgeons, instrument damage is more likely to occur, as are increased expenses and shorter equipment life."

That’s precisely why education of all staff who care for and handle the equipment throughout the daily use cycle is so critical to the success of any preventive instrument maintenance program. It’s also why facilities should partner only with repair and maintenance companies that are committed to providing ongoing education and training, sources stressed.

"A true service partner should provide a customer with an executable plan to reduce the severity and incidence of critical equipment failures. Across the board, vendors should show the facility why they spend what they spend and how to improve their processes to reduce those costs," reasoned Bo Mundy, CEO of IMS’ Surgeon Support Solutions Division.

Ongoing education of CS employees is imperative, particularly in light of staffing shortages and frequent turnover that can leave gaps in proper care and handling of instrumentation.

"Since proper protocols for cleaning, disinfection and sterilization have a huge impact on patient safety and repair prevention, ongoing training in this area is vital," noted Eddie Garces, president of Olympus Medical Equipment Services/MPRG and Olympus vice president/chief quality improvement officer. To assist in that effort, Olympus recently mobilized a team of Endoscopy Support Specialists to work with customers on-site, helping them make improvements in equipment inspection, reprocessing protocols and proper care, handling and storage techniques.

Technician inspecting a rigid scope for centration

A strong instrument maintenance program should begin with a thorough assessment of current hospital procedures for the handling and management of instruments, according to Cardinal Health’s Williams. During this assessment, she said it’s common to find several very specific aspects of instrument maintenance that create challenges in the OR and purchasing department. Using six sigma processes, Cardinal Health’s OnSite Services uses a tray quality audit that measures the sigma level of the tray quality (six sigma is defined as 3.4 defects per million "opportunities"). Translated to instrument set assembly, defects can include such issues as dull scissors, incomplete sets or bioburden.

"While everyone strives for a sigma level of 6.0, it is not uncommon to see much lower levels in a random audit," Williams explained. "Once the ‘defects’ have been identified, a focused education program can be designed to correct the issues."

Use of saline for rinsing or storing instruments, which damages devices, remains a common problem, as is the improper use of enzymatic detergents, which can also wreak havoc on instruments if used in excess. As Purtell explained, the adage "more is not always better" certainly applies here.

When it comes to scopes, it’s fluid invasion that tops the list of costly and preventable repairs, pointed out Garces. "Fluid invasion is almost invariably the result of inadequate leak testing practices. When you’re working with endoscopes, a little extra care in handling goes a long way in repair prevention." Careful adherence to original equipment manufacturers’ usage instructions and care and handling protocols is also essential to extending the life of instruments and ensuring that they remain in good working order, he stressed.

Another common misconception that can be cleared up by ongoing staff education is that soaking an instrument in instrument milk solves the issue of a tight ring-handled forcep or a sticking Kerrison rongeur, pointed out Steve Dillon, instrument product specialist for Integrated Medical Systems International Inc. (IMS), Birmingham, AL.

In reality, this approach is only a band-aid covering a larger problem. "The underlying cause of the original problem is still present after the soak and will return after a couple of times through the SPD."

Inadequate inventory and improper set rotation further adds to facilities’ instrumentation woes. As Dillon noted, it’s often easier to pull a tray that is on top of the stack, even though the ones on the bottom aren’t being used nearly as often. "This can lead to higher repair costs because use isn’t spread over an entire inventory. It is focused on a select few trays that happen to be in the right place at the right time."

Healthcare organizations must also facilitate ongoing education within their own ranks. One effective strategy is to designate a liaison between OR and SPD staff to build an understanding of the effects of instrument migration and poor care and handling as they relate to surgeon satisfaction and, ultimately, patient outcomes, Dillon continued.

In MedCentral’s case, Narance credits the lion’s share of the facility’s success with effective, proactive instrument maintenance to education. Partnering with Spectrum Surgical, staff gleaned much-needed knowledge on how to handle, process, and inspect and tag instruments.

"If staff is unaware of what they’re looking for with instruments and aren’t educated on common mishaps and how they might be contributing to damage and premature replacement, then the maintenance program won’t be successful in the long-term," he said. "Any repair vendor should be engaging their clients to be attentive and look for things that will impact the way an instrument functions." Narance does his part by educating his customers throughout the facility on safe handling and proper inspection.

"I believe every manager should have their own mini ‘road show’ that lets them train and engage the workforce and customer base."

In virtually every aspect of healthcare, solid documentation is a core requirement, and that’s certainly the case where preventive instrument maintenance is concerned.

Scanlan’s Easy-Tag can be used on every type of device — not just ring-handled ones. It allows the type or description of the repair to be written on the tag and is still legible after the decontamination/wash cycle.

For optimal success, healthcare organizations should team up with an instrument repair and maintenance service provider that will help them establish a preventive maintenance schedule for all instruments in the facility’s inventory based on usage.

"Repair vendors should be inspecting and tagging instruments that are cracked, broken or missing parts. [They] should also be assisting in the development of repair frequencies," Vrancich added.

Instrument tracking capabilities, afforded by vendor software systems, are an important part of the process because they can ensure that the right instrument sets are repaired at the right time. Keeping a running history of repairs is also beneficial because it can pinpoint repair trends and identify problems that can then be addressed and corrected through additional staff education. Also helpful are vendor reports that include photos of damaged or misaligned instruments that can then be shared with their healthcare customers.

"Having a maintenance program that is scheduled, documented and shared among team members within the operating room, central sterile and purchasing departments assists in constructive communication," assured Williams. A lack of solid documentation regarding repair history, she stressed, can lead to negative reactions and finger-pointing, instead of constructive problem-solving.

Hospitals should also seek the services of repair vendors who can demonstrate innovation, measurable savings, multiple service capabilities, and a track record of satisfied customers – not those that focus on low line-item pricing. Above all, service and repair companies should be willing to serve as a true extension of the sterile processing department; that is, willing to work directly with staff and hospital customers to drive long-term success and ensure that the SPD is poised to fulfill its duties as the instrumentation experts they are.