5 Steps to Improved Instrument Care


Reorganized trays, team togetherness and real-time tracking are the keys to success.

Components of some power tool sets used in the OR suites at The Johns Hopkins Hospital in Baltimore were going missing — and it was costing the facility nearly $150,000 a year to replace them. Something had to be done to limit the losses and preserve the occasionally tenuous relationship between the ORs and central sterile processing (CSP). The hospital's leadership decided to implement a series of steps aimed at improving how the departments communicate and coordinate their handling of the costly tools.

In the first six months after changes were made, the bills for replacement parts plummeted to around $5,000. Two years later, the average annual cost of replacement parts was just $3,500. The process improvements they implemented to achieve those incredible results can serve as a blueprint for flowing instruments through your facility in ways that will save money and avoid unnecessary headaches.

1. Identify issues

The first thing that has to end is the OR and CSP pointing fingers in the other's direction when an instrument goes missing, according to Brenda Nack, MSN, RN, CNOR, CSSM, CRCST, director of sterile processing at Johns Hopkins. "We created an instrument committee to get to the bottom of the issue and focus on solutions," says Ms. Nack. "Our successes started when we began to communicate and collaborate, and departments stopped blaming each other."

As it turns out, how the components of the 10 different power tool sets used by surgical teams at Johns Hopkins were organized in the instrument trays was a big part of the problem. It was very disorganized — sometimes the sets were transported to CSP in a single layer, other times they arrived double- or triple-stacked. Some were labeled; some were not.

"We had a really good blame game going on," says Carol Gentry, MSN, RN, CNOR, nurse manager in the pediatric OR at Johns Hopkins.

After the committee met, both sides realized they had culpability in the problem. Improvements were made when each side realized how expensive instruments are — a missing handpiece could cost $15,000 to replace. Also, they needed to understand that replacement parts could take several months to arrive because the hospital first had to approve the expense, and the manufacturer didn't always immediately have the needed item in stock.

2. Reorganize instrument trays

SEEING IS BELIEVING A central processing technician at Johns Hopkins Hospital uses a verification check sheet to make sure all the components of a power tool set arrived from the OR.   |  Johns Hopkins Hospital

Make sure instrument trays are well-organized to make it easier to confirm all components are present or to notice missing items. The instrument committee's first step at Johns Hopkins was to audit the contents of the power tool sets. Some of the parts, either because of obsolescence or lack of use, were eliminated from the sets before the storage containers were redesigned, says Nick Breslin, CRCST, a CSP manager who oversaw a large part of the reform efforts.

The team met with product vendors to create custom containers for all the power sets. Each container was labeled and dividers were set up, so every piece of each power set had a designated home within the trays.

Often, trays offered by manufacturers of power tool sets were deficient, says Mr. Breslin. They were plastic, not durable and had to be blue wrapped. John Hopkins opted for rigid containers for all power sets. The rigid containers worked better because they included baskets and dividers to offer the level of customization needed to keep individual components organized.

3. Create visual aids

Make sure OR staff and reprocessing tech have access to quick-reference guides to ensure instrument sets are complete when they arrive in their areas and before they're sent to their next destination. CSP leadership created visual check sheets for all power sets. The sheets include photos of the entire set. Each item is identified — including the names, reference numbers and ID codes for each part — and has a total count for how many parts are in a set. This makes it easier for the OR and CSP staff to visually validate the components in the tray. The sheets are kept in a verification book, and copies are in the decontamination and clean sides of CSP, as well as in the OR.

Using the same set of reference materials helps the departments communicate when an item is missing, says Mr. Breslin. The books are also used as teaching tools and are shown to new employees as they're trained on instrument verification techniques, adds Ms. Nack.

Johns Hopkins has since expanded its use of photo-filled verification books to instrument sets beyond power tools. "They're a great way to monitor the components of problematic or highly expensive sets you need to keep a close eye on," says Mr. Breslin.

4. Institute real-time checks

It's useful to know in an instant where instrument trays, and even individual tools, are located within your facility. When power tool sets come to the decontamination area from an OR, a member of the CSP team should count the items in the set. If all the items are accounted for, the set can move forward to the decontam process. If an item is missing, it's a full-stop and the CSP tech — with the assistance of the verification book — identifies the missing piece and reports it to the CSP supervisor. The supervisor confirms which part is missing and — with the help of instrument tracking software — determines where the set was last used and who last used it, then calls the OR supervisor. Often the missing piece is found misplaced with an implant set or in a tray for a different instrument set.

Our successes started when we began to communicate and collaborate.
— Carol Gentry, MSN, RN, CNOR

Depending on the model, tracking software employs barcodes, RFID tags and etched markings to help staff locate specific tools in minutes. They're also helpful in monitoring wear and tear on instruments and can help improve the accuracy of case-costing analyses.

At Johns Hopkins, all instrument sets are scanned before being used in the OR, when they arrive at CSP for reprocessing and again at the decontamination area. "If something is missing, we can go back to the assembly person, frontline clinical staff or reprocessing tech at the decontamination area to ascertain the instrument's location, or what happened to it," says Ms. Gentry.

Meanwhile, the OR staff determined that the best way to prevent the loss of items on their end was to count the items in each power set before and after they were used in each case. At first, there was pushback, but it was quickly allayed, because the counts take only a minute or two.

"The reality is that most drill sets have four or eight parts — the one we have with the most components has 21 parts, so while the idea of the counts seemed onerous when suggested, it really wasn't a big deal," says Ms. Gentry.

5. Conduct ongoing monitoring

Drift can occur from newly implemented practices, so be sure to monitor your staff's compliance with updated instrument care protocols. Leadership at Johns Hopkins audited the counts and contents of the power tool sets to make sure the new protocols were being followed, but the oversight effort was discontinued shortly after it started as compliance was high almost immediately. Ms. Nack attributes the high level of compliance to not only the better organized instrument containers, but to the higher level of communication and collaboration between the ORs and CSP.

The two departments continually meet to foster a climate of cooperation and trust. Understanding what pressures the other department faces each day helps. In addition to the instrument committee meetings, new SPD employees visit the ORs as part of their orientation process.

"We send the new CSP techs to the ORs to understand the complexity of what the OR staff faces, from sharing the power tools among all the ORs to simply seeing the enormity of the tasks they face each and every day," Ms. Gentry says.

The ongoing interaction helps CSP understand how cleanups during and after cases are never-ending issues for OR staff. The rush to turn rooms over quickly can result in mistakes such as losing a part to a power tool kit. They can be left on mayo stands and wind up in the linen or the trash at the end of the case, meaning they're lost forever.

CSP, meanwhile, is charged with following increasingly meticulous, complex and time-consuming IFUs from manufacturers in order to deliver sterile instruments to ORs to ensure safe patient care. In addition to being told to take their time and get it right, they're also told to hurry up from anxious OR staff who want their cases to begin on schedule.

On the same page

Implementing these steps at Johns Hopkins significantly improved the hospital's instrument reprocessingpractices — only three power tool pieces went missing in the first six months after the new protocols were put in place. When surgical team members and central sterile techs began to understand the other department's perspectives, they worked together to dive into the causes of the missing parts and were open to brainstorming solutions together. OSM

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