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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