Imagine this: In the OR, an orthopedic surgeon finds that the cannulated drill bit she is using has a guide wire stuck in it from a previous case. Now flecks of hardened, autoclaved blood from another patient have just contaminated her patient's wound. She stops the case to provide treatment for wound contamination. Suddenly the procedure is taking longer, the surgeon is angry, the patient is compromised and your cost to do that case has rocketed. All this because the 30-second step of checking and cleaning the lumen of a drill bit - a task that would have cost all of 20 or 30 cents to do right in the first place - was neglected.

Or: Surgical staff are setting up for a procedure and, while preparing instruments on the back table, the surgical technician discovers what looks like blood or tissue in the serrations of a clamp. He has touched other sterile supplies when he discovers this. The patient is in the holding room, anesthesia is almost ready for him and the surgeon is scrubbing. Now the grim task of fixing the problem begins. Staff alert the surgeon and anesthesia that they consider the room and sterile supplies to be contaminated because of the dirty instrument found in the set. Staff begin the process of tearing down and then setting up the room again. All the opened supplies, gloves, gowns and suture, now become part of the waste stream - they must be thrown out. Depending on the procedure, they could be looking at hundreds if not thousands of dollars wasted. Not to mention the embarrassment and poor relations this can create with the patient, surgeon and the teams subsequently scheduled for that OR. All because of a simple oversight in the cleaning of an instrument.

Prevention of incidents like these can be traced to your investment in labor, training and equipment for your facility's reprocessing area. Taking decontamination and sterilization seriously can save you tens of thousands of dollars annually; but part of taking these processes seriously is supporting them financially.

There are many factors to consider when looking at the economic side of your facility's decontamination and sterilization processes. Expenses can be subtle and difficult to quantify, especially when you're talking about something as abstract as potentially preventing surgical site infections. But there can be serious negative consequences for any facility that doesn't perform decontamination and sterilization properly: reduced surgeon trust in the facility, additional stress and frustrations within the surgical team, and increased scrutiny by regulatory groups and payors if infection rates are higher than peer facilities' rates. On the pages that follow, we'll look at how you can best ensure that you use your reprocessing budget effectively.

Economics of Decontamination

1 Labor. Your highest expense associated with decontamination will be labor. The hourly wages or salary requirements of staff performing these duties are a good starting point for analysis. If you use RN staff or surgical technicians to process instruments, your expenses will be higher than if you were to use central services technicians, whose wages typically are less than those of surgical techs and RNs.

Say an RN wage is $20 per hour; it would cost 33 cents per minute to clean surgical instruments. Imagine how costly that could be if you use only manual cleaning methods. You're looking at one or two minutes per instrument for disassembly, brushing, flushing and more - and that's if our example RN works fast. Even if you process in automated washing equipment, the time needed to prepare items is a factor.

Now, say that you use a dedicated central services tech whose pay is $12 per hour. Your per-minute expense is now 20 cents - a decrease of 40 percent. Extrapolate the savings out over a year, and you can see the advantage of having the proper skill mix devoted to instrument processing activity.

Of course, you need to go beyond the hourly wage to determine if this would be a true savings. Is your caseload large enough to support a dedicated technician who performs processing duties? If your center is small, it makes more sense to cross-train RNs to share duties in central sterile, rather than to hire another employee entirely.

Certified sterile techs make sense in a large freestanding ASC or hospital, though. As you'll often need an entire department of reprocessing techs in such settings, you should also consider the cost of staff turnover when calculating your labor costs.

Recruitment, training and covering for an employee who has left your facility can cost thousands. Try to keep turnover low by emphasizing employee recognition (especially because central sterile staffers aren't on the front lines to see the rewards for what they do) and retention. Such programs may increase costs in the short run, but a happy, stable central sterile department will save you money over time.

2 Utilities. Engage a good facilities engineer to help determine your true expenses. Trying to calculate the cost per cycle of operating automated washers is difficult to do if you rely solely on manufacturer's representations of steam, water and power usage. Get input on the actual consumption at your facility from someone who maintains the systems. Once that's done, you can get an idea of what the annual expense is to operate the decontamination area.

Saving money on utilities is difficult at best, as seasonal and unplanned hikes in power and water prices seem to be happening regularly. As this can adversely impact your budget, it's best to build the increases into your annual budget as a precaution. Also, if you're using a deionized water system for rinse cycles, add the annual cost of filter replacement to your calculations.

3 Supplies and consumables. These are your high-volume costs: soaps, detergents, lubricants (for automated washers with lube cycles), brushes, pipe cleaners, disinfectant solutions and more. You should also include the cost of personal protective equipment for staff who perform decontamination. Some helpful hints in cost control:

• Make sure the washers are set to deliver the recommended amount of detergent and lubricants (based on machine and detergent manufacturer instructions). More is not necessarily better (in fact, it may contribute to poor results) and serves only to increase consumption and cost.
• Make sure staff are properly trained on the care and handling of instruments and equipment they'll be cleaning. You can easily spend thousands of dollars on repairs if delicate items are damaged during the cleaning process or if pieces and parts are lost or misplaced. Power tools and other non-immersible items can very easily sustain damage if exposed in critical areas to water or disinfectants.
• Plan on replacements for brushes and cleaning aids that may wear beyond their effectiveness. Your techs should vigilantly ensure brushes are cleaned on a daily basis and replaced when the bristles are worn or absent.

Decontamination is widely recognized as the critical first step in the sterilization process. As such, it's rapidly becoming a breeding ground for new technology in processing equipment and products. This has created an influx of new items to consider and evaluate for inclusion into your processes. When doing so, remember that there are certain inescapable expenses associated with adhering to proper techniques and following recommended standards and practices.

If your facility strives to implement and promote best practices, you'll be on the alert for methods to improve your processes. In this quest for improvement, keep in mind the potential effects on the process outcomes. It's helpful to include others (always consult a trusted infection control practitioner for input) in your cost-benefits analysis. Sometimes in falling victim to a sales pitch you may only increase your operating costs without necessarily improving the outcomes of your cleaning process. Try to avoid frequent product changes that may confuse staff - imagine finding out your decontamination staff weren't properly mixing chemicals because the dilution or instructions for use had changed. You could then be wasting materials or, worse, not achieving the full efficacy of that product.

4 Equipment maintenance. Unless you work in a larger facility or one affiliated with a hospital, you're probably using contracted services. Annual expenses for repairs (including parts and labor) should be fairly easy to calculate based on invoices and service records. Maintain all records of services performed on decontamination equipment as part of the documentation for the sterile processing area. Budget regular preventative maintenance and emergency repairs for each year. If you employ a maintenance person or engineer, ensure he's properly trained as a biomedical equipment technician and that he's equipped with all up-to-date, necessary reference manuals.

5 Replacing capital equipment. Although today's automated washers are of high quality, you'll someday need to replace them. When you buy equipment for the decontamination area, get the manufacturer to give you the expected useful life of the device. This will aid in planning and budgeting for future expenses. You can estimate some equipment life based on cycles of use or similar parameters that central sterile staff can easily monitor. Even if your equipment is in great shape and never breaks down, eventually the manufacturer will no longer support it, and parts availability may become an issue. When evaluating decontamination equipment, involve the staff that use it to help you determine what you might actually use and when. This could save you money when considering the many accessories available - many of which might not be useful or practical and will ultimately sit idle in storage.

Also anticipate what features you may want to have later. For example, a printer on a washer is a nice feature to have. Although not currently required by any regulatory authority, printouts may well be part your sterile processing validation and documentation processes. It's easier and cheaper to get the machine configured the way you want it now rather than trying to retrofit it later.

The number and type of cases you do are critical factors to consider in evaluating your needs, and your sales rep should provide benchmark data on how they affect your selecting the size and appropriate numbers of automated equipment. Visit other facilities to view the equipment in operation.

Economics of Sterilization

1 Labor. Here again, consider the frequency and volume of your sterilization needs. If your center's case volume supports staffing the processing area for a full eight-hour shift, you'll likely benefit from having a dedicated sterile processing tech (or techs). I can't overemphasize the importance of this behind-the-scenes duty when it comes to consistent productivity and providing sterility assurance and a high level of confidence for all frontline healthcare workers.

Under most circumstances, a single tech could probably support all the processing functions of an average two- to four-OR surgical facility. This dedicated processing technician - who can staff both decontamination and sterilization as needed - can actually lower your cost of sterilization by providing a stable and predictable salary expense for this function. Using the lowest-cost, most appropriate job class for reprocessing also provides you the overall benefit of stable and reliable performance, which is tougher to achieve when available nurses or surgical techs are assigned in a patchwork fashion and at higher rates of pay. Further, minimizing your potential liability from sterilization failures or bad outcomes is well worth the cost of hiring a trained and consistent employee.

2 Utilities. Consult a facilities engineer to help quantify and calculate cost per cycle. You can then extrapolate that information to cycles' cost per year. You may be surprised at the differences between what your actual facility expenses are and those quoted to you by various sterilizer manufacturer reps; remember, they're using averages and not costs adjusted to your location.

I've found the greatest amount of variability in low-temperature sterilization because of varying volumes - these are more specialized sterilizers, not your everyday, heavy-duty autoclaves. Get a handle on the volume of loads one of these machines would process before you evaluate low-temperature sterilizers for purchase. Choosing the wrong machine or technology can throw off your sterilization expenses. Again, don't forget to factor in the always-rising price of water and electricity, and any consumables in the case of low-temperature units.

3 Supplies and consumables. Consider the following routine supply expenses for sterilization: wrappers, all process-monitoring supplies (chemical and biological indicators), autoclave tapes, filters or other items associated with rigid containers and, in the case of low-temperature technologies, sterilant. To arrive at the cost to process an item, factor in the following:

• cost per minute of labor,
• how much time to allocate for an item (wrap, load onto cart, unload),
• cost of packaging material (wrap, peel pouch, rigid container),
• cost of type of chemical monitor used in each package, and
• the approximate cost in utilities to run each sterilizer cycle (you may have to divide this by the average number of items per load).

One dissimilarity between sterilization and decontamination is that there are monitoring and documentation requirements representing absolute costs in sterilization that are currently optional in the decontamination process. Although it would add expenses, you may want to consider the potential benefits of exceeding minimum requirements and adhering to all published best practices. Review your sterilization policies and procedures to help you get started in identifying new products and processes to consider when looking at the economic picture in your sterilization area.

4 Equipment maintenance. Don't think of it as merely fixing a broken part; think of it as maintaining the functionality of central sterile. If you don't have multiple sterilizers to provide backup, how long can you perform cases without a functioning sterilizer? Is your instrument inventory sufficient to sustain you with sterile sets for all your patients for two or three days? Are you willing to operate if you have to flash everything for that period of time because the main autoclave is down? What happens if an emergency arises (an especially important consideration in the hospital setting)?

If your sterilizer isn't maintained properly, you could see additional operational expenses in the form of recalls for possible failures, higher reprocessing costs and even a damaged facility reputation if you have to frequently explain to surgeons or patients there may have been a sterilization failure. Budget for unexpected repairs, routine monitoring and preventive maintenance.

5 Replacing capital equipment. Most sterilizers have a finite life, usually a number of cycles rather than years of service. Plan to replace these machines close to the manufacturer's guidelines; if you try to overextend the life of a sterilizer, you may experience increased costs in other areas. You may also find that your insurance carrier requires data on sterilizer usage or that city or county officials could refuse to certify your operations if, during an inspection, they deem the equipment unsafe. In many areas, you may need a permit to operate a vacuum sterilizer because it can be considered a pressure vessel. Planned, programmed replacement will help best manage this expense and prevent any unpleasant surprises.