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         Clinical intelligence for supply chain leadership

 
 

INSIDE THE CURRENT ISSUE

March 2014

CS Connection

 
 

SPD weathers hustle, bustle with OR tussling

by Kara Nadeau Della Vecchia

To reduce instrument turnover time and repair frequency, OR personnel should spend time understanding what goes on in the Sterile Processing Department — and vice versa.

While it seems like it should be a pretty straightforward relationship, interactions between the sterile processing department (SPD) and operating room (OR) are plagued by friction, strife and even animosity in many healthcare facilities.

To understand some of the hot button issues between these two departments, I posted discussions in "PeriOperative Department Professionals" and "Sterile Processing Department Professionals" groups on the social networking website, LinkedIn, asking OR and SPD staff to share the challenges they face in working together. While the PeriOperative group was silent on the issue, those in the SPD group were quick to respond with comments such as:

"The OR needs to understand that SPD services more than just the OR. ER and L&D are just as demanding and needy."

"The OR needs to understand what "Turn-around" time is for a tray. It is definitely not the 15 to 20 minutes given for a room to be turned around. Depending on the hospital, and tray, this can be 4 to 6 hours."

"The OR techs do not put the instruments back in the pans they came out of. Board more cases than we have instruments for. Expect us to turn around a set in 30 minutes."

"When the OR calls us in SPD asking for a sterilized surgical set, it is wonderful when they speak clearly. What a difference it makes when I can understand them!"

Michele DeMeo

In this article, Healthcare Purchasing News explores some of the top friction points between the OR and SPD, as reported by professionals in these departments and industry experts, and present their suggestions for overcoming these challenges in ways that benefit both parties — and the patients they serve.

"The relationship between the two departments ultimately will impact patients. The better the relationship, the better the patient outcomes and physician satisfaction. Like it or not, we are each customers to each other, not just for the doctors or patients, just like any business," said sterilization expert Michele DeMeo, CRCST, CSPDT. "The subtle nuances naturally built within the confines of the structure or foundation of each department are no different than the tiny fractures or cracks that occur in a concrete building foundation. It is how they are addressed that seems to dictate whether or not they remain simply cosmetic differences or true danger spots."

He said/she said

Both sides agree that a basic lack of understanding about each other’s profession fuels much of the friction between the SPD and OR. We asked those with experience in the SPD, OR and in some cases both departments their opinion on what the SPD and OR should know about each other’s work environment and responsibilities to improve workflow and relations between the two.

Turnaround times and unrealistic expectations

Multiple SPD professionals stated that OR staff do not understand how long it takes to properly clean, disinfect, sterilize, assemble, package and deliver a tray. Most noted that the OR dramatically underestimates turnaround times, placing unrealistic expectations on the SPD.

"OR staff typically doesn’t understand that it takes three to four hours to sterilize a tray properly because most don’t have insight into or experience with what actually happens in the SPD," said Heather Margiotta, CSS Work Leader, Virtua Memorial Hospital. "Many think if they send down a tray it will be fully sterile within an hour."

Jean Sargent

On the flipside, Jean Sargent, Director, Advisory Solutions, MedAssets, explains how SPD professionals often don’t understand the pressures placed on OR staff to quickly turn around the OR for the next case and how errors in instrument preparation impact patient care and case flow.

"The SPD needs to understand the pressure OR staff is under in terms of turnaround times, keeping the physicians happy and maintaining a sterile field, and how all of this is impacted when they receive a set from the SPD with a missing instrument," said Sargent. "Incomplete sets are a troublesome issue for both sides and cause a great deal of friction between the two. Often, the SPD and OR get into a back and forth around how and when the instrument got lost with each party pointing to the other as the culprit."

Richard Schule

As someone who has worked in both the OR and SPD, Richard Schule, MBA, BS, FAST, CST, FCS, CRCST, CHMMC, CIS, CHL, AGTS, Director of Clinical Education for Steris Corp., agrees there can often be complacency within the ranks, due to poor communication, education, and structure, both OR and SPD professionals do not understand nor appreciate the important role and contributions the other makes impacting patient care.

"There can be little room or time for improvisation when it comes to missing, incorrect or improperly cleaned instruments at the bedside during a procedure," said Schule. "In most cases, the patient is placed in various states of analgesia, hence the urgency for completing the procedure as quickly as possible. When SPD is unable to provide dependable, reliable product to the clinician at the bedside, then the patient may suffer."

It’s a two-way street

Tracey Rapp

While the OR expects the SPD to deliver complete sets that are organized appropriately and ready for use, SPD professionals point out that the sets returned to them from the OR are often "a mess," containing instruments soiled with blood and tissue and haphazardly placed in case carts.

"When case carts get to the decontamination area with the instrument sets scrambled and mixed up, it is extremely difficult and time-consuming to process the instruments," said Tracey Rapp, Clinical Operations Director, Integrated Medical Systems International Inc. (IMS). "This can result in missing instruments and incomplete trays. Many times, delicate instruments and specialty equipment are damaged when placed under a heavy item or misplaced for transport. Instruments can also be damaged when heavy bioburden is left on them for long periods of time."

Carmen Ferriero III, Associate Director of Sterile Processing Operations at Albany Medical Center, points out how most failures in instrument processing are not SPD or OR issues but global issues that both parties must work collaboratively to address.

Carmen Ferriero

"While instrument issues tend to fall on SPD, we are the last people to touch them. Just think about how many hands these instruments go through. You have the scrub techs and nurses counting them, sorting them, putting them back together, and handing them off. Surgeons have them in their hands and in some cases the vendors too. Because there are so many parties involved, instrument management must be thought of as a global process and not just an SPD-related issue," said Ferriero.

Shifting schedules

Because ORs are dealing with living, breathing patients, nothing is ever set in stone and priorities frequently shift due to a variety of factors — from an unexpected emergency case to a patient arriving late for his/her surgery. SPD professionals stress the importance of OR staff keeping them abreast of changes so they can prepare the needed instruments accordingly.

"If SPD knew a doctor was running late or a case was ‘bumped’ or even ‘jumped to first’ this would prevent re-work and/or at least enable them to shift priorities," said DeMeo. "SPD will only work on the instruments that are deemed most important in the moment. Well ‘the most important’ or needed ones sometimes change and we need to know that. Screaming at SPD because a tray that was sent down at 10 a.m. and is not done by 2 p.m. when on the surgical schedule it appeared it was not going to be needed and yet a case was added in the morning… that is not necessarily SPD’s fault."

On the other hand, DeMeo points out that SPD staff must be flexible to accommodate true emergencies when they arise.

"I would imagine OR would like SPD to keep in mind that they are faced with a collage of shifting needs, too," added DeMeo. "Demanding physicians and patients needing the best care immediately is imperative and statements like ‘sorry we don’t have that to send to you’ are not going to be received well and shouldn’t be, either."

"In my 20 years as a surgical technologist I have had the privilege of working with a number of excellent surgical teams working on trauma cases or elective procedures with the rare intra-operative complication, dictating an immediate need for instruments," adds Schule. "You don’t have time to improvise sometimes. It can be very critical. Unless you have the training and experience necessary to perform and/or support procedures in the clinical setting, it can be difficult to convey to the SPD an appreciation for the urgency sometimes needed in specific situations."

Instrument terminology

Both SPD and OR professionals expressed frustration with regards to instrumentation terminology and knowledge. It makes the SPD’s job more difficult when OR staff members request instruments using their own terminology for the devices rather than using the proper names. On the other hand, OR staff become frustrated when they ask for instruments and SPD staff members do not have in-depth knowledge about the devices and their use in patient care.

"There have been times when a nurse or OR tech has called down to SPD asking for a specific device and if it is unavailable they will ask the SPD professional to recommend an alternative," said Margiotta. "What OR staff don’t understand is that while SPD staff are trained to understand the instruments themselves and how to care for them, most do not have in-depth knowledge around what those devices are used for in the OR so they can’t simply suggest a substitute. OR staff get frustrated with this but they must take into consideration the role of the SPD and the extent of training these professionals receive in regards to the devices."

Overcoming challenges via communication, collaboration

We asked professionals from the SPD and OR and other industry experts for their recommendations on how these departments can overcome these and other challenges, removing hurdles and making everyone’s work lives easier, more efficient and more effective. They provided the following suggestions.

Identify an ally

For an SPD or OR staff member who would like to improve interactions between the two departments, experts recommend that he or she should identify an ally within the other group. Schule suggests seeking out an individual who is confident, knowledgeable, vocal in his/her department, a visionary and someone whom others listen to and respect.

"Good communication and interpersonal skills are critical to fostering better relations between the OR and SPD," said Schule. "Efforts such as this must be led by strong individuals who serve as cheerleaders for their respective departments. Once you’ve identified a potential ally, sit down with them over coffee to discuss challenges and expectations then collaborate on whatever is necessary to move forward."

At Ferriero’s facility, both the SPD and OR report to the same person, creating "shared initiatives and facilitating an effective problem solving process by making issues team issues rather than compartmentalizing them down to departmental issues," explains Ferriero. As in many facilities, the SPD previously reported to materials management. Ferriero comments:

"Even though SPD is not clinical in the traditional sense of the word, everything we touch touches the patient so it makes sense for the SPD and OR to report together," said Ferriero. "This reporting structure enables the right people to be at the table when brainstorming ideas and making decisions around instrument handling and processing. Someone in materials management likely knows that the hospital purchased $1500 forceps but they typically don’t understand what they are used for and why they keep getting broken. These are the kinds of issues the OR and SPD are best suited to address. When you bring the right people to the table that’s how you can make the best decisions not just for the patients but also for the whole team."

Open the lines of communication

The experts agree that the SPD and OR must open lines of communication between the departments paving the way for better understanding of each other’s expectations, needs and challenges. Sargent suggests a member of the SPD department attend the daily OR morning meeting to hear about the latest case schedule and room assignments. That way, the SPD can be prepared to address last minute changes and challenges that arise.

"By being there in the OR meeting the SPD liaison has first hand knowledge of what’s occurring that day and issues that are likely to impact his or her department," said Sargent. "For instance, the OR may have nine cases scheduled that all require the same instrument set while the hospital only has eight of these sets. The OR doesn’t necessarily know there are only eight sets so having that SPD professional in the room enables both sides to identify this issue up front and set in motion steps to address it, such as collaborating to get one set back to the SPD as soon as possible so it can be ready for that last case of the day."

To better understand the challenges each are facing with regards to surgical instruments and equipment, DeMeo recommends SPD and OR staff conduct rounds in each other’s departments, hold joint department meetings, have collaborative educational sessions and share both the wins and areas for improvement together.

"The SPD and OR need to see themselves as a team, not just when they want to be included, but always, through the good and tough times. That’s how a team is built," said DeMeo.

Walk in each other’s shoes

Matt Ofenloch

Many facilities have implemented programs where SPD and OR professionals spend time in each other’s departments to understand one another’s processes and challenges. Matt Ofenloch, Staffing and Development Manager, IMS, explains how this not only fosters better understanding of each other’s responsibilities, but can also help a facility better maintain its surgical assets.

"Having SPD staff spend time in the OR and observe a surgery from start to finish would allow the SPD staff to understand all important aspects of the surgery," said Ofenloch. "They would gain understanding of how each instrument is used and why it is important to that procedure and patient."

"In return, having OR staff members each spend a day or two in SPD would allow them to understand the decontamination, assembly and sterilization processes," added Ofenloch. "OR staff would better understand why it is important for them to keep instruments organized in the original trays and use an instrument pre-soak spray. By understanding the complete cycle of use and reprocessing, these two teams can work together to reduce instrument turnover time and repair costs."

Ferriero explains, at his facility, every new OR technician must spend four days in the SPD to learn about the department’s process and issues and see them first hand. In addition, Ferriero has hired two OR technicians as case cart coordinators to help bridge the gap between the SPD and OR. He notes how these individuals have brought with them inside knowledge from the OR that has helped the SPD make informed decisions about how they prepare and deliver sterile supplies.

"These individuals now serve as our main service lifeline to the OR," said Ferriero. "When the OR calls down to SPD they get somebody on the other end of the line who speaks their language and can easily decipher nicknames for products and can also troubleshoot and provide effective alternatives in certain situations where the desired product may not be available. It has been eye opening for these techs to be on the other end of the process and live the challenges we face each day when communicating with the OR."

DeMeo notes how it is equally important for SPD staff to experience the OR and the challenges its staff faces in patient care.

"The SPD staff is a little sheltered in the fact that they don’t see the tension that happens in the OR and often do not have to face an angry physician when there is an instrument issue," said DeMeo. "When a problem surfaces OR staff cannot simply walk away. They must deal with it immediately and safely for the patient’s sake. This is another reason I have always advocated SPD rounding for each case in the core of the OR."

Implement quality systems

According to Schule, another key to successful SPD/OR interactions is for facilities to implement quality management systems around the handling and preparation of instruments and equipment both in the SPD and OR. Schule is currently co-chairing AAMI/ST/WG86 Quality Systems for Device Reprocessing, a new document the Association of Medical Instrumentation (AAMI) is tasked with developing on implementing quality systems for reprocessing medical devices.

"Once we remove the emotion surrounding an event and can focus on the elements and requirements of the process we can begin to improve the working relationship," said Schule. "More specifically, stakeholders must begin to embrace and appreciate opportunities gained by implementing quality management systems as a fundamental foundation in developing a structure of support to include regular communication and scheduled education around a system of documents and reoccurring process audits.

"We cannot simply state we expect instruments to be delivered to SPD at the end of a clinical procedure in the same manner received by the OR without educating the end user on the rationale," he added. "This is no different than the OR expecting instruments to be present and functional within a trauma tray without educating on the importance and rationale behind the clinical implications and the impact on patient safety."

Establish a plan and stick to it

Most relationships require constant attention and work to remain successful and mutually beneficial, and the alliance between the SPD and OR is no exception. Those interviewed stressed the need for the two departments to establish a solid plan by which to improve communication and collaboration, hold their staff and each other’s accountable, and stick to it.

"They need to have a full game plan — here’s what the problems are, here are the solutions and here’s how we will achieve them," said Sargent. "I recommend starting with a defined plan of action, encompassing the next six months, that includes specifics on how the two departments will work together on a daily, weekly, monthly basis."

All agreed that SPD and OR staff must be proactive in their efforts to reduce friction and foster better relations between the departments. Ferriero encourages SPD staff members to seek out OR staff, speak with them and ask questions.

"As a department leader I try to encourage my staff to get out there. When they have some downtime I encourage them to talk with the OR nurses during the different shifts," said Ferriero. "I also get our staff in to see surgeries when they can so they can watch how instruments are used and ask questions."

Margiotta too stresses the need for SPD professionals to be proactive in their interactions with the OR, stating:

"SPD techs should take the initiative to go to the OR, observe and ask questions. Actions such as this go a long way in overcoming the frustration that occurs on both sides as a result of miscommunication and lack of knowledge."