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Several  studies  have  calculated  the  comprehensive  costs  of  sterilizing  and  packaging  reusable  instrumenta<on  for  each  incremental  use,  with  es<mates  ranging  from  €0.47  –  €9.20  (roughly  $0.59  -­‐  $11.52  US)  per  instrument,  depending  on  instrument  type1,2,3.    Adler  et  al4  show  that  between  34%  and  41%  of  the  costs  of  sterilizing  and  packing  each  instrument  is  due  to  personnel  costs,  and  the  remaining  66%  to  59%  of  the  cost  of  processing  each  instrument  is  due  to  deprecia<on,  resource  usage,  and  quality  checks.    This  leads  us  to  believe  that  significant  cost-­‐cuDng  may  be  achieved  by  reducing  unnecessary  steriliza<on,  wear  and  tear,  and  processing  of  instruments  that  are  exposed  to  an  unsterile  environment,  but  not  actually  used  during  a  procedure  [Fig  1].    Moreover,  Greenberg,  et  al  showed  that  a  more  streamlined  instrument  tray  with  fewer  instruments  can  be  both  cost-­‐effecHve  and  safe  for  the  pa<ent5.      This  study  aimed  to  quanHfy  the  percent  uHlizaHon  of  instruments  among  the  most  commonly  used  instrument  trays  in  surgical  cases  for  Otolaryngology  and  three  related  surgical  services:  Plas<c  Surgery,  Bariatric  (endoscopic)  Surgery,  and  Neurosurgery.    We  further  aimed  to  calculate  the  costs  associated  with  tray  and  instrument  sterilizaHon  processing,  and  to  assess  a  cost-­‐savings  es<mate  to  elimina<ng  unused  instruments  from  surgical  trays.    

Assessing the Magnitude and Costs of Instrument Utilization in Otolaryngology Surgical Instrument Trays Emily Walker Stockert, MBA; Alexander Langerman, MD

Department of Surgery, Section of Otolaryngology – Head and Neck Surgery, University of Chicago

Introduc<on   Results  (Con<nued)  

Conclusions  

A  total  of  49  procedures  and  237  individual  trays  were  observed.    The  average  instrument  uHlizaHon  was  13.0%  for  Otolaryngology  (±4.2%),  15.5%  for  Plas<c  Surgery  (±2.9%),  18.2%  for  Bariatric  Surgery  (±5.0%),  and  21.9%  for  Neurosurgery  (±1.7%)  [Fig  2].    

Figure  1.  The  Instrument  Tray  Cycle:  A  Long  and  Complex  Process.    Data  collecHon  was  conducted  on  each  of  the  areas  in  bold.  

References  

Percen

t  U<liza

<on  

Results  

Our  study  demonstrates  that  the  percent  uHlizaHon  of  instruments  in  Otolaryngology  surgical  trays  is  low,  and  this  trend  is  consistent  across  other  special<es.        We  also  found  that  cleaning  and  re-­‐packaging  an  instrument  that  went  unused  in  the  opera<ng  room  costs  on  average  $0.10  per  instrument  by  conservaHve  esHmates,  and  up  to  $0.29  per  instrument  using  more  inclusive  cost  metrics.    This  amount  is  non-­‐trivial,  especially  when  considering  the  volume  of  instruments  processed  each  year.    A.en<on  to  tray  composi<on  may  result  in  immediate  and  significant  cost  savings  in  the  form  of  reduced  central  sterile  processing  labor.  

1.  Adler  S,  Scherrer  M,  Ruckauer  KD,  Daschner  FD.  Comparison  of  economic  and  environmental  impacts  between  disposable  and  reusable  instruments  used  for  laparoscopic  cholecystectomy.  Surg  Endosc.  2005  Feb;19(2):268-­‐72.    

2.  Demoulin  L,  Kesteloot  K,  Penninckx  F.  A  cost  comparison  of  disposable  vs  reusable  instruments  in  laparoscopic  cholecystectomy.  Surg  Endosc.  1996  May;10(5):520-­‐5.    

3.  Prat  F,  Spieler  JF,  Paci  S,  Pallier  C,  Fritsch  J,  Choury  AD,  Pelle<er  G,  Raspaud  S,  Nordmann  P,  Buffet  C.  Reliability,  cost-­‐effec<veness,  and  safety  of  reuse  of  ancillary  devices  for  ERCP.  Gastrointest  Endosc.  2004  Aug;60(2):246-­‐52.    

4.  Adler  S,  Scherrer  M,  Ruckauer  KD,  Daschner  FD.  Comparison  of  economic  and  environmental  impacts  between  disposable  and  reusable  instruments  used  for  laparoscopic  cholecystectomy.  Surg  Endosc.  2005  Feb;19(2):268-­‐72.    

5.  Greenberg  JA,  Wylie  B,  Robinson  JN.  A  pilot  study  to  assess  the  adequacy  of  the  brigham  20  kit  for  cesarean  delivery.  Int  J  Gynaecol  Obstet.  2012  May;117(2):157-­‐9.    

6.  Average  CSP  hourly  wage  at  our  ins<tu<on  

At  the  level  of  the  individual  instrument  tray,  we  noted  an  inverse  relaHonship  between  instrument  uHlizaHon  and  number  of  instruments  per  tray.    The  more  instruments  included  in  a  given  tray,  the  lower  propor<on  that  were  actually  used  during  the  procedure  [Fig  3,  Box  A].  

Methods  Data  were  collected  through  direct  observa<on  by  a  trained  inves<gator.    Opera<ng  room  instrument  usage  data  were  collected  from  rou<ne  (weekday,  non-­‐emergent)  surgical  procedures  over  a  period  of  8  weeks.    Labor  <me  required  for  cleaning  and  repacking  instrument  trays  in  central  sterile  processing  was  tracked  during  peak  volume  shiqs  for  2  weeks.    The  data  were  analyzed  and  summarized  using  descrip<ve  sta<s<cs  and  linear  regression.    We  applied  the  following  equa<ons:  

 Tray  A  UHlizaHon  =  ICountUsedA  /  ICountTotalA  

 

Where:  §  ICountTotalA  =  #  of  instruments  included  in  tray  A    §  ICountUsedA  =  #  of  instruments  from  tray  A  that  were  used  in  the  procedure    

 Cost  of  Cleaning  and  re-­‐packing  Instrument  I  =  Ew*(Ict  +  Ipt)  

 

Where:  §  Ict  =  Average  ?me  in  seconds  to  clean  one  instrument    §  Ipt  =  Average  ?me  in  seconds  to  pack  one  instrument  §  Ew  =  Average  CSP  employee  wage  per  second:  

§  $19.84  per  hour6  ÷  60  min  per  hour  ÷  60  seconds  per  minute  =  $.006  per  second  

0%  

20%  

40%  

60%  

80%  

100%  

OHN   PLA   BAR   NEU  %  Instruments  un   87.0   84.5   81.8   78.1  %  Instruments  Used   13.0   15.5   18.2   21.9  Standard  Devia<on                              ±4.2                                                    ±2.9                                                    ±5.0                                                    ±1.7  

Total  Procedures  =  49  Total  Trays  =  237    

Figure  2.  Total  Instrument  UHlizaHon  For  all  Trays  Opened,  by  Specialty    

0%  

20%  

40%  

60%  

80%  

100%  

0   25   50   75   100   125   150  

Total  Number  of  Instruments  Per  Tray  

Per  Tray  Instrumet  U<liza<on  

Figure  3.  Per  Tray  Instrument  UHlizaHon  vs.  Total  #  of  Instruments  per  Tray.      Box  A:  Low  u*liza*on  with  high  instrument  counts.    Box  B:  Trays  where  ≤  1  instrument  was  used.        

A  total  of  61  trays  were  observed  being  decontaminated,  and  a  total  of  35  trays  were  observed  being  packed  prior  to  steam  steriliza<on  in  the  on-­‐site  central  sterile  processing  unit.    A  significant  linear  relaHonship  was  noted  both  for  <me  to  decontaminate,  as  well  as  <me  to  pack  vs.  number  of  instruments  per  tray  [Fig  4].  

Addi<onally,  of  the  237  trays  opened,  40  (17%)  of  these  trays  had  only  one  or  zero  instruments  used  aqer  opening  [Fig  3,  Box  B].    This  happened  most  frequently  with  Otolaryngology  trays:  16/73  trays  or  22%  of  the  <me  [Table  1].  

Cases  Observed                                          18                                                          12                                                            13                                                          6    

Specialty   #  of  Trays  where  ≤  1  Instrument  Used     #  Trays  Observed  

Frequency  per  Observed  Tray  

Otolaryngology   16   73   22%  Plas<c  Surgery   10   58   17%  Bariatric  Surgery   10   76   13%  Neurosurgery   4   30   13%  Total   40   237   17%  

Table  1.  Frequency  of  Opening  a  Tray  for  ≤  One  Instrument,  by  Specialty  

Using  recorded  labor  <me,  we  calculated:    

Cost  of  Cleaning  and  re-­‐packing  Instrument  I  =  Ew*(Ict  +  Ipt)  

Ict  =  4.02  s  Ipt  =  12.51  s  

Ew=  $0.006  per  s    

$0.10  per  instrument  =  $0.006  per  second  *  16.53  seconds  

It  was  determined  that  an  incremental  instrument  takes  4.02  seconds  to  decontaminate  (R2  =  0.68),  and  12.51  seconds  to  pack  prior  to  steriliza<on  (R2  =  0.83).  

0  

500  

1000  

1500  

2000  

0   20   40   60   80   100   120   140   160   180  

Time  to  Decontaminate  per  Instrument:  Slope  (s/#)  =  4.0179  

N  (trays)  =  61  

Time  to  Decontaminate  Tray  (s)  vs.  #  Instruments    

0  

500  

1000  

1500  

2000  

0   20   40   60   80   100   120   140   160   180  

Time  to  Pack  Tray  (s)  vs.  #  Instruments    

Total  Instruments  per  Tray   Total  Instruments  per  Tray   N  (trays)  =  35  

Time  in  Secon

ds  

Average  (s/#):  21.85  (±  29.18)  Median  (s/#):  =  7.67  

Time  to  Pack  per  Instrument:  Slope  (s/#)  =  12.513  

Average  (s/#):  17.08  (±18.60)  Median  (s/#):  =  12.23  

Figure  4.  Linear  Regression  Analysis:  Time  to  Decontaminate  and  Pack  Instrument  Trays  vs.  Number  of  Instruments  per  Tray    

Box  A  

Box  B  

Factoring  in  Adler  et  al4  research  on  the  costs  of  sterilizing,  packing  and  processing  instruments:    

34%  and  41%  of  the  costs  are  due  to  personnel  66%  to  59%  of  the  costs  are  due  to  deprecia?on,  

resource  usage,  and  quality  checks    

EsHmate  increases  to  $0.24-­‐$0.29  per  instrument  

Elimina<ng  80  unused  instruments  from  one  tray  that  is  pulled    10  <mes  a  week  for  50  weeks  could  result  in  savings  between:  

80*$0.24*10*50  =  $9,600  per  year  80*  $0.29*10*50  =  $11,600  per  year    

Time  in  Secon

ds