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Infection Prevention
Handling Equipment on Loan
Dan Mayworm
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

Dan Mayworm Q How should we handle equipment on loan for surgical procedures? Our current policy is that loaner equipment surgeons request must be brought to our facility the day before the procedure for decontamination and sterilization. Our concern is that some of this equipment (because it's very expensive) is being used in several hospitals and surgery centers - wherever the surgeon practices - and we can't be sure that every facility handles and reprocesses as we do. Some have come into our department quite obviously inadequately cleaned after they'd been used. This is a growing problem, as more and more specialty surgeons are using our facility.

Dan Mayworm\ A Borrowed devices should go through the same acceptance procedures as newly purchased equipment. Don't deviate from your policies just to appease a visiting surgeon or any other surgeon who has privileges at your facility - management should make the rules clear in advance of granting privileges to any surgeon.

That is something that's easier said than done unless you have a very enlightened management who understand the consequences of using potentially dangerous loaned equipment. It's true that some surgeons have a very cavalier attitude about the care and handling of their equipment and will fight anything that will hold up or delay their surgical procedures. You can only avoid this by having written procedures that you consistently enforce - and that management backs up. For help writing your policy, see "Components of a Loaner Instrument Policy" and visit writeOutLink("www.iahcsmm.com",1) and writeOutLink("www.ashcsp.org",1) for the joint position paper on loaner instrumentation by the International Association of Healthcare Central Service Material Management and the American Society for Healthcare Central Service Professionals.

Components of a Loaner Instrument Policy

Your policies and procedures for consignment or borrowing surgical instrumentation from other healthcare facilities or vendors should include sections on acquisition, accountability and disposition, says the Certification Board for Sterile Processing and Distribution (www.sterileprocessing.org). Highlights:


  • Designate those within the facility who can accept and fill the requests, as well as those responsible for transport of instrumentation to central service.
  • When loaner instruments are requested by a surgeon, or from a company or another facility, advise central service of what's ordered; what's needed; how it's arriving (such as a courier service or sales representative) when it's arriving, written manufacturer's recommendations for processing requirements; where it will be received; when it's needed (time/date of case and surgeon) and how/when it will be returned.

Non-hospital-owned instrumentation/equipment includes that loaned by a manufacturer, on consignment, borrowed from other institutions or physician-owned. For any type, you must identify accountability for lost or damaged instruments and equipment. Develop documentation for the acceptance of the instrumentation/ equipment, including its condition and the time frame.

Non-hospital-owned instrumentation poses issues of financial liability. All instruments brought into the institution for a particular case should comply with the ASHCSP/IAHCSMM position paper on loaner instrumentation. Develop a count sheet or packing list to be used from the time the instrument is received to its pick-up for return.

If instrumentation is lent/borrowed by another facility, document the process, usually on the lender's lend/borrow form, which should include the date the item was sent, the item number, item description, whom it was sent to, the date it was received and the initials of who received it. Trays and instruments should not be released without the consent of the perioperative director or designated individual. All information should be communicated, documented and posted.

Develop a policy to ensure the return of items to the vendor or other healthcare facility, including

  • documentation of instrument reprocessing;
  • who will coordinate the return;
  • the time frame for return;
  • how it will be delivered; and
  • who will receive it.

Dan Maywor\m A sterile item brought into the facility as a single-use, pre-sterilized item is no problem. I wouldn't recommend that you take the item from the package and process it unless the package is clearly damaged. A few surgeons will bring in perfectly good, sterile items and ask you to flash them, unaware that this will probably result in a less safe product. Don't flash any medical device unless you know that it's safe to do so.

You could ask that the physician (or, more likely, the physician's office) provide documentation from the previous user regarding how it cleaned and processed the device. This won't absolve you from your responsibility to provide safe and effective instrumentation. Your lawyer could draft a release form, but he'll probably tell you it's best to follow your written procedures and not deviate except in very rare cases where you can determine the safety and effectiveness of the device without its going through your processing.

Any new equipment should be brought to the attention of staff before it's used; if in doubt, get written processing instructions from the manufacturer before you use any piece of equipment. Finally, and I can't stress this enough, train everyone in your system, as well as your vendor reps, on your policy manual.