KIND OF A DRAG? Use a piece of latex to determine whether a tool is dragging and needs to be sent out for repairs.

The best way to extend the lives of delicate and expensive surgical instruments is to keep them from wearing out or getting damaged in the first place. Everything wears out eventually, but at our hospital we've developed a system that puts an absolute premium on keeping instruments in the best possible condition for the longest possible time. That's important, because at UPMC Presbyterian, our flagship hospital here at the University of Pittsburgh Medical Center, we handle more than 2,000 cases a month, which means we're processing just south of 4 million instruments a year. It's a huge investment and we can't afford to cut corners or treat instruments with anything less than the care they deserve.

Like most facilities, we used to follow a schedule for preventive maintenance. Heavily used trays were sent out monthly, lower movers maybe every quarter or so. But that approach left us vulnerable. What if a pair of scissors or a rongeur becomes dull on the first day of that cycle? You're not going to have it PM'ed for another 28 or 30 days.

Now, there are 2 things to keep in mind here. One is that if you do a good job of getting instruments repaired before any damage gets worse, it increases longevity. The second is the X factor. Thankfully, I've never witnessed anything like this at UPMC, but we've all heard stories of frustrated surgeons tossing scissors across the room because they didn't like the way they're cutting. That, to put it mildly, tends to be detrimental to instruments. The simple fact is that well-maintained instruments help keep tempers in check, and our approach has generated a lot of really positive feedback from our surgeons.

How do we do it? The key is that we inspect instruments in sterile processing as we go through our pick lists and assemble trays. We've done multiple in-services with the instrument companies, training our staff on what to look for. So anything that has a really specific functionality — like a scissor or a rongeur or a needle holder — ends up being inspected once or twice a day, instead of just once a month.

EASY REFERENCE Extend the life of surgical instruments by following IFUs to the letter.

We hold needle holders up to the light and make sure they align perfectly. For scissors, we have a clip card on the side of our rigid containers. They need to be able to make a perfect cut. We'll also test it on a piece of latex, and if there's the slightest amount of drag, we'll pull it off the tray, get a backup and send it out for sharpening. Staff also check at the point of assembly to make sure parts are moving fluidly. If not, they spray on a little lubricant.

I know what you're thinking. People assume our approach must be time-consuming. It does take some time to train people and make sure they're doing the right things every time. But once you've done that, it becomes just another routine step in the process. It adds maybe 30 seconds per tray. And the results — the longevity and the quality of the instruments — speak for themselves.

To the letter
We're talking so far about instruments that bite, cut, grab or align. That functionality needs to be closely monitored and maintained. And of course it starts in the OR. We don't ask a lot from OR staff, but we do ask them to remove any major debris and spray equipment down before they load it up and send it back to us. We have a spray product we keep in the OR — one that combines a surfactant-based gel with corrosion inhibitors — so we make it pretty simple for them. The spray keeps the equipment moist and helps with the cleaning when it gets to the decontamination area.

We all know that regulatory bodies are really focused on making sure instruments are cleaned, because if they're not, they can't be sterilized. I've seen a lot of changes in instrumentation over the years, with everything becoming very service-specific, so training comes strongly into play here, too. To properly maintain instruments, you need to know how to disassemble and clean them. When you're talking about something as complex as an endoscope, there are a lot of nooks and crannies, and a lot of lumens.

The key is to follow the IFU to the letter. That's true with every instrument, but especially with scopes. We process about a thousand endoscopes a month and we don't leave anything to chance. We do competencies twice a year for our staff on all scopes, but we also provide backup in the way of a software package that gives us access to thousands and thousands of IFUs. Everyone in sterile processing has a touch screen, so if someone gets confused or needs a reminder, he or she can click on the screen, key in a password and pull up the appropriate instructions. We've tried to make it as easy and efficient as we can, so there's no temptation, or excuse, to cut corners.

Armored approach
I'm also a big believer that rigid containers do a better job of preserving and protecting instruments than blue wrap. Rigid containers are like armor. They protect what's inside them much better. On top of that, if the wrap tears, whatever's inside is considered contaminated.

We did some analysis when we started switching over and found that on top of providing better protection, the containers pay for themselves in a year and a half or 2. So we're gradually building our inventory, trying to containerize everything.

In the meantime — and this points to another weakness with wrap — we've put edge guards on our shelves. We've found that people in a hurry sometimes drag instruments off shelves, instead of lifting them. That can cause tears if instruments aren't in rigid containers.

Naturally, there's a tradeoff in all of these measures. It takes a little more time and a little more money to care for instruments in a way that maximizes their performance and life expectancy. But training is the key, and manufacturers provide in-services free of charge. You can bring them in as often as you want, to make sure your sterile processors are up to speed and know what they're looking for.

And while it's true that an ASC, or any facility that doesn't have an internal preventive maintenance department, would need a larger backup inventory if it wants to be as strict as we are about taking less-than-optimal tools out of circulation and having them repaired, I think it's justified. The last thing you want to do is give a dull piece of equipment to a surgeon. Not only will you lose credibility, you'll also likely end up with further damage and have to replace that equipment that much sooner. As an alternative, spending an extra couple of hundred dollars on additional inventory is likely to be a sound investment.