When Instruments Grow Legs: A Story of Ownership, Waste, and Surgical Assets Gone Missin'



Imagine you work the cash register at a local retail chain (Target, Walmart, Macy's, whatever). And every night as you count out your cash on hand, you happen to come up a couple hundred of dollars short.


But here's where you really have to use your imagination:


Imagine if everyone knew your were short, but no one -- not your boss, not your coworkers, not even loss prevention -- nobody at all did anything about it.Or, imagine if no one noticed you were short at all. And they continued to be oblivious for weeks, months, and even years.


Well, you've just been introduced to the life of surgical instrument asset management in countless hospitals across the country. And if you're surprised, those of us on the inside of CS/SPD surely are not.


Even with total inventories valued in the hundreds of thousands up to multi-millions, very few hospitals have the faintest idea of the what their true surgical inventories are at any given time, where they are, or if certain assets recently grew wings and flew away. In short, current surgical asset management practices are a perfect recipe for waste, loss, and yes, even theft.


The Expectation of Chaos and the Cost of Expediency


If you were to step into any medium to large-sized hospital in the US, and find your way into the OR/CS-SPD departments, you would see a spectrum of different levels of surgical instrument management. Current estimates put electronic surgical asset management software adoption at about 50% of CS departments in the country -- which means only half of US hospitals have any kind of barcode scanning of instrumentation going on. Everyone else is processing via pen and paper -- which can obviously get the sets sterilized, but provides very little ability to track instrument location, value, and replacement costs.


At the practical level, even those CS departments who do have electronic asset management capabilities are almost always under-utilizing those programs. Because of this, it is not uncommon for there to be a very real, if limited, "culture of chaos" in CS/SPD and the OR as it relates to instrument-level asset tracking. On a daily basis, instrumentation gets lost at some point during the use/reprocessing cycle, removed for repair/replacement, substituted, borrowed, and broken. Entire sternal saw sets (complete with attachments and battery packs) end up in the trash, doppler probes that need minor repairs have their cords cut by impatient surgeons, bandage scissors end up in hurried circulator's scrub pockets, and towel clips are left clipped on surgical drapes and thrown away. If an accounting were done at the end of each surgical day, the results in many facilities in the US would be jaw dropping.


But such accountings are rarely done, and definitely not done as matter of industry best-practice. Instead, hospitals spend exorbitant amounts of money replacing, repairing, and updating instrument inventories with very little data showing how well they are managing their current surgical assets. So what's the answer? How do we overcome this high cost of chaotic expediency?


On Clinical-Accountants and Perioperative Accountability


There are no easy answers to the cultural mess we are in. The god of "OR turnover times" has spoken, and every OR nurse and surgical tech in this country feels the pressure of its unbreakable commandment to shave off seconds anywhere they can. Often times these seconds are saved in a quick breakdown of instrument trays in the OR room, which is an undeniable cause of much instrument loss, breakage, and set migration. But the pressure doesn't end in the OR. That same strain on time and resources ripples forward into the CS/SPD department, demanding that limited staff reprocess insufficient inventory, as quickly as possible, in order to support poorly* scheduled surgical cases (*booked without regard to the availability of instrumentation).


Add to these process stressors the reality that sometimes instruments are intentionally removed from the workflow, whether it be through outright theft or unauthorized instrument migration (scrub pockets, workstations, secret OR cubby holes for "safe keeping"). With all of this opportunity for surgical asset shrinkage, there is a very real need for what I'll call front-line clinical accounting -- which is just a fancy way to say, the users AND owners of these surgical assets must commit to regular, real-time audits of tray contents and total inventories. Yes, I do mean mandatory in-room, post-operative surgical instrument counts by the OR team -- every case, every time.


Related to the need for real-time clinical-accounting, is the necessity of an holistic approach to perioperative accountability for the protection of surgical assets; one that follows the entire lifecycle of the instrument, from CS to Storage to OR and back to CS again. This means ownership of loss, waste, and theft must be shared across all perioperative departments, not solely on the users or the reprocessors of surgical instrumentation. This ownership is not just a budgetary thing, however, it's also a cultural thing. Surgeons, nurses, surgical techs, OR coordinators, CS/SPD technicians and leaders must be held to a standard of accounting for the assets that grow legs and walk away under their watch -- and that standard must be a team standard, with cross-disciplinary collaboration to find real and lasting answers. There is no such thing as effective lone ranger asset management.


The Dawn of Instrument Data and the Power of Price


Before any of this will mean anything, however, hospitals must first deal with the dirty and incomplete surgical asset inventory data they currently have: countsheets without instrument product numbers, tracking systems with outdated inventory totals, unidentifiable instrumentation, and all manner of free-floating backup inventory not contained any any trays or peel packs. Perhaps as important as this data cleansing initiative, will be the critical step of developing a replacement pricing model for every instrument set in their facility. I would recommend the unorthodox step of actually labeling your entire surgical inventory with the total replacement cost of each tray (i.e. Major Basic Tray - $6575, Universal Screw Removal Set - $13,860, etc). If that sounds like I'm asking you to put a price tag on your instrument trays, I am. All members of the perioperative team should be brought face to face with the true value of the inventory that is passing through their hands, and be encouraged to act in accordance with a robust surgical asset management program.


Until facilities know the actual value of their surgical assets, they will never be able (or willing) to track, account for, and improve daily management of them. However, once a true, data-driven baseline of surgical assets is developed, and a program for clinical accounting and perioperative accountability is put in place, the power of price can help create a culture that eschews chaos and commits to driving down the high cost of pure expediency.


That's my two cents. What say you?

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