By Angela Lewellyn, LPN, CRCST, CHL, CSPDT
Instrumentation prioritization is a critical job for sterile processing (SP) professionals and helps keep surgeries on track and ensure that complete trays and other necessary items are available when needed for the operating room (OR). Among the most valuable methods for prioritizing instrumentation lies with the surgical schedule. Scheduled cases and add-on procedures should determine how SP teams prioritize instrumentation needed to build case carts for the following day’s business demands. Typically, the surgical schedule is posted the day prior to when the instruments are needed. All SP professionals, including technicians, leads, supervisors and liaisons, should know how to read the schedule.
SP professionals can prioritize instrumentation requests by categorizing them one of three ways: want, need or waste. Many instrumentation demands are considered urgent or are requested with a sense of urgency. Those in SP can determine priorities in one of these categories and control some of their daily duties by instituting processes that control these ongoing issues.
Building Trust to Capture Truly ‘Urgent’ Requests
Often, an urgently needed (wanted) instrument requested from an OR team member arises due to an urgent need for the patient as the team prepares for a procedure. Sometimes, the OR’s requests for extra instrumentation comes from a lack of trust between the OR and SPD. The OR team may request items to ensure they have instruments that a surgeon or provider “might” want or need. It’s important to note that OR teams may lack a strong degree of trust if the SPD provided incorrect instrumentation in the past, or if the instrumentation wasn’t received in the timeframe needed to ensure a successful procedure.
Other urgent requests may stem from a surgeon requesting an unordinary instrument; therefore, the OR team may place that item on a surgeon’s preference list for future cases, even though the surgeon may never request the item again. Such circumstances can create tremendous pressure (and greater workload) for the SP team. Developing an OR/SP committee can help.
Usually, I initially recommend getting together twice a month to discuss both departments’ needs. This interdisciplinary committee will ideally be comprised of an SP technician, surgery liaison, OR service coordinator and surgical technologist. I recommend these professionals for a collective and comprehensive approach to addressing mishaps and proactively discussing needs. In doing so, we can gain trust and appreciation for each team.
Requests that fall under the “Need” category are usually standard instruments needed to perform surgical procedures (these are typically provided on a surgeon’s preference card). An SP team can determine the needed items from the preference card for each scheduled case, usually the day before the procedure. To prioritize these needed items, the SP shift coordinator should over-communicate the needs. They can post needs on a communication board, huddle about these needs at the beginning of the shift and communicate those needs again in huddles at shift changes. Instruments/trays that were not completed and still in need can be communicated at this time.
Once the needs are determined, the SP lead/supervisor for the shift can delegate or assign the need to technicians in the decontamination and assembly areas. The coordinator should provide the decontamination technician with a notification on priority need, especially with any turnover or add-on case. Those needs should then be checked off the list as technicians complete/fulfill them.
In some instances, a scenario of “taking from Peter to pay Paul” may occur. The challenge for SP professionals is that as the instruments undergo sterilization, are cooled and then transferred to specific case carts, an immediate needed instrument may then be taken off the completed case cart that was designated for a next-day case. Sometimes, this transaction is performed without communicating a retrieved item to the SP team. Many times, the OR does have an immediate need for an instrument and, in haste, removes the first one found. Their sense of urgency may not allow them to properly communicate their action.
The lack of communication creates several issues. While the SP team is completing the needs/priority list, they sometimes have a false sense of satisfaction that all needs were met. When the next day arrives, the OR may request the items and state that the case cart is incomplete. This creates of sense of urgency in both teams – a sense of frustration in the SPD and, possibly, a sense of mistrust between the OR and SP teams. One of many solutions may be to have the OR and SPD develop a process of incoming and outgoing products. This can be established by a tracking system and/or the delegation of a liaison whose role is to monitor need requests and the delivery of those needed items. All requests and delivery of needed items should be documented to further promote effective communication and accountability.
Aim for Accurate Count Sheets/Preference Cards
Waste (providing instruments that weren’t needed) is an issue in many of the facilities that the advantage support team assesses. The problem, in part, lies in incorrect count sheets or count sheets that have not been updated for the surgical team or surgeon in specific services (e.g., neurology; orthopedics; cardiovascular).
Again, the surgical team may open a complete tray just to retrieve one item. An example: the surgical team may need additional long hemostats or needle holders and they know there are some in a general instrument set; they open an entire tray to retrieve just one or two items.
There are several solutions for addressing instrument waste, including having a static storage area of processed general or commonly used instrumentation, or a service cart of commonly used items for each specific surgical service. The cart should be located in or near the surgical suites that perform that service. A tracking system that allows a surgical circulating nurse to request the extra item(s) is another approach to address the issue. The tracked request should be directed toward the liaison on the SP team and delivery should be documented. According to one Healthcare Purchasing News article, “Room for improvement in SPD could be the organization of the backup instrument area (cabinets, wall, drawers, etc.) to improve the ease of finding replacement instruments for sets that frequently return to the decontamination area of SPD missing instruments, such as towel clamps, Adson forceps and Allis clamps, just to name a few.”
Categorizing instrumentation according to waste, want or need can help prioritize requests in the SPD and better meet customer and patient needs. The three categories also will help SP and OR professionals devise and implement process improvement initiatives.
 Jelks M. An overview of lean transformation in sterile processing. Nov. 20, 2017. https://www.hpnonline.com/sterile-processing/article/13000925/an-overview-of-lean-transformation-in-sterile-processing
– Angela Lewellyn, LPN, CRCST, CHL, CSPDT, serves as director of surgical services for Advantage Support Services.