Ambulatory surgery centers, like most facilities, cannot typically afford to purchase all of the instruments needed for the wide-range of procedures they perform. This, coupled with changing technology and a lack of storage space, leads most ASCs to employ the use of loaner instrumentation.
The use of loaner instrumentation presents many challenges for surgery centers, says Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, president/CEO of Seavey Healthcare Consulting and formerly the director of the sterile processing department at The Children's Hospital of Denver. "You don't always get those instruments in enough time to appropriately reprocess them, and you should avoid the use of immediate-use sterilization," she says. "In addition, for those [staff members] who are going to be scrubbing — whether it's a technician or a nurse — if they've never seen those instruments before, it can present challenges to efficiency and safe patient care."
Ms. Seavey recently worked with the International Association of Central Service Materiel Management on a management of loaner instrumentation position paper (pdf). Included in the position paper is a checklist which Ms. Seavey developed. "It's a quick, down and dirty checklist [ASCs] should use any time they have loaner instruments."
Ms. Seavey discusses the nine steps in the checklist and adds a final step to complete the "before and after" cycle of receiving and returning loaner instrumentation.
1. Sterile processing is notified of loaners prior to receiving them. The first step is to inform your sterile processing department or the staff member who is overseeing sterile processing that you will be receiving loaner instrumentation and what is included in the delivery. "It's important so they can plan their day, so they know that it's coming," Ms. Seavey says. "But the most important piece of it is that they can make sure they have the manufacturer's instructions for use so that they know ahead of time that they are able to follow those instructions. For instance, if the instructions say [the instrument] must be cleaned in an ultrasonic cleaner, then you have to have an ultrasonic cleaner or else you're not going to be able to clean those items correctly."
2. Instruments are received in facility at least two working days (48 hours) for existing loaner sets and three working days (72 hours) for new sets before scheduled case. Receiving the instruments 2-3 days in advance provides time to identify problems, properly clean the instruments and run biological indicators if there's an implant and have those results available before the instruments are used. "For new sets, the recommendation is 72 hours because for the person in the operating room who is going to be scrubbing the case, it would be nice for them to have an in-service and be familiar with the instrumentation before they open it up to do the case," Ms. Seavey says. "It's not just an efficiency issue but also a patient safety issue."
3. Inventory list is provided/available. "When we're borrowing instruments, we're not borrowing forks, knifes and spoons, which is what I call the routine, everyday instruments," she says. "They're complicated instruments and they're usually coming in multiple instrument trays, and often they're things we're not familiar with. You need not only an instrument list but ideally you should have illustrations or pictures because sometimes if you just have an inventory list with a lot number, you don't know what the instruments are used for."
4. FDA-cleared manufacturer written instructions are available for cleaning, packaging and sterilization processes. The FDA clearance is the only way you can ensure the processes have been validated. "You need the FDA-cleared instructions because those have been validated to be efficacious for cleaning as well as sterilization," Ms. Seavey says. "It's not just the cleaning instructions but you also need the sterilization instructions. They've been validated so following these precise steps will ensure efficient sterilization."
5. Inventory and quality check is completed. Performing the inventory and quality check to make sure nothing is broken or missing is not only a patient safety issue but also a financial issue. "You don't want it to get up to the OR and find you have an instrument missing that's vital to the case and then you can't do the case," she says. "Also, if you're doing an inventory before, and inventory after (see step #10), then you're assured you're sending back what you received and the vendors are not going to come back and say 'this screwdriver is missing' and charge you for it."
6. Multiple trays are numbered and labeled (with patient and surgeon). This labeling system allows you to keep track of the similar items you received. "You might get a loaner set of instruments with five trays it, so then you should label it tray one of five, tray two of five, etc., and then ideally on that it should have the patient's name and surgeon's name on it," Ms. Seavey says.
7. Trays do not exceed 25 pounds. This is the national limit recommendation from AAMI and AORN. "That came about because of OSHA regulations: problems with ergonomic issues as well as sterilization and drying issues," she says.
8. All instruments are in good condition, with no rusting or pitting. "You want to make sure that the instruments don't have any discoloration or rust," Ms. Seavey says. "The instruments might be completely there but then maybe you have pliers, a screwdriver or retractor that's rusted — you don't want to use that on the patient. If there is [an instrument in poor condition], you can note that when you send it back to the vendor. There's a financial issue there."
9. Container is in good condition, with no rusting, tape, residue, etc. If the instrumentation comes in a rigid container, you should check to ensure there are no cracks or dents in it, she says. If you discover any cracks or dents, the container may have been dropped on the way to your facility and now you may not be able to maintain the sterility of the instrumentation. You also want to check the container for damage so you can inform the vendor about the problem and avoid a repair charge.
10. Perform inventory prior to returning instrumentation. "This is more of a financial issue, making sure you're sending back what you received and checking to make sure nothing was broken on your watch," Ms. Seavey says.
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