Ten considerations for reprocessing instruments off-site

If you are responsible for multiple acute-care hospitals, each with aging sterilisation departments, the prospect of combining these CSSDs into one facility has likely crossed your mind. It’s a concept that has traction in Europe, and it’s certainly crossed the minds of the team at Sterequip who have invested large amounts of time and money getting their centres up and running.

There are many upsides to centralising your reprocessing operations, and some obvious downsides. Here are some things to think about in deciding whether this makes sense for your health service.

1. People

Healthcare is a team sport, and without a complete team, it’s difficult to succeed. Some team members are not comfortable with change. Their arguments against moving sterilisation off-site are often related to response time in the theatre. Surgeons and perioperative staff are often concerned about the loss of immediate-use sterilisation, despite AS/NZS4187:2014 (s6.1.2) cautioning against standard use of this practice. [See inventory below]

On the other hand, creating an off-site CSSD has upsides for the reprocessing team.

• a combined off-site reprocessing facility increases the possibilities for career progression for reprocessing staff members. The manager of a centralised facility fulfils a larger, higher-profile role than the managers of individual CSSDs.

• due to the separation from the operating suite, there is less traffic demanding special treatment for their particular requirements (fast tracking) [see inventory below]

2. Space

Decanting the CSSD out of your hospital(s) transfers this function from high cost/high opportunity cost space within the hospital to low-cost space in an industrial park or on one of your campuses. This may allow you to add in one or more additional revenue-generating operating rooms, expand the size of one or more of your operating rooms to allow for modern practice, and to free up more space for sterile store.

This may be particularly useful as procedure volume increases.

3. Utilisation

Another enabler of off-site sterilisation is better utilisation of capital equipment. This means that you can own less of it and work it harder. This is somewhat in line with the airline business model – planes are only making money when they’re in the air; and your sterilisers are only adding value when they’re full of instruments. It is particularly true of things like water treatment plant – instead of one per hospital, you can have one central water treatment plant, and with only one set of water quality monitoring costs, rather than multiple.

4. Volume / Capacity

The goal here is to provide enough capacity to manage each hospital’s volume of soiled RMDs, while minimising the value of capital equipment and floor space required to reprocess effectively and efficiently.

Delivery batch sizes are necessarily larger off-site than on-site. In an on-site situation, a team member pushes a trolley of soiled instruments to the CSSD. In the off-site situation, a driver backs a van or a truck up to the CSSD. It is beneficial to spread the deliveries of soiled RMDs across the day to the extent possible, and to smooth out the demand on the facility as much as possible. This could impact on delivery frequency, vehicle size, and facility location.

5. Logistics

One of the main additional ongoing expenses in off-site sterilisation is the cost of drivers and vehicles to get soiled RMDs to the off-site facility, and processed RMDs back to the right hospital. Choice of location is important, and there are a range of trade-offs to be made. The main trade-off is land cost against travel time to each of your hospitals. A component of the time equation is also loading and unloading, so some investment in making this quick and easy is sensible.

6. Inventory

One of the truisms in this transition is “stock is safety”. If you insert 30 minutes of driving to your CSSD and 30 minutes back again, your best possible response time increases by an hour. Depending on your volume of soiled RMDs, transport to or from a particular hospital may only take place daily.

The degree of forward planning required to incorporate this is not usually a challenge for hospitals [see systems below]. But it does require a higher level of inventory of RMDs. An example might be an ophthalmology OR which may turn over a given tray of cataract instruments three times in a day. If each tray can only be processed once per day, a higher number of trays are required. This may be a significant investment.

Returning to the idea “stock is safety” – what happens if or when things go wrong? A good risk assessment is an important part of planning a move off-site:

• How likely is a major traffic delay, and what are the consequences?

• How likely is a power outage at the off-site facility, and what are the consequences? (this could be balanced against the consequences if it happens in-hospital). How much back-up and redundancy makes sense?

• What are the trade-offs between more inventory, more frequent, smaller deliveries and increased up-time at the facility?

7. Systems

Managing and tracking trays and instruments is an important function, and this requires a system which reaches into operating rooms, sterile stores and reprocessing areas. Several vendors have systems which are proven to work well in an off-site reprocessing context.

Because OR staff cannot walk into the CSSD and request fast-track processing, other means of communication are required. The good systems are able to relay high-priority requests to the CSSD, and to return an ETA to the operating suite so that they can plan around it if required.

A further step in sophistication is to link the OR schedule with the trays and instruments required to fulfil those procedures. This highlights any stock shortages well before they become an issue.

In general, we support up-and-coming players with cost—effective solutions. In this area however, our recommendation is to choose a software vendor who can demonstrate that their system works on an operational multi-site organisation. Several European sites have their hands full helping their software vendor complete their product development while simultaneously trying to service their client hospitals.

8. Endoscopes

Endoscopes don’t fit well into this arrangement. This is partially because scopes don’t travel well, and because the capital cost of expanding your scope fleet to manage the low stock turnover. In all the examples I’ve seen of off-site sterilisation, endoscopes are reprocessed within the hospitals. This is possibly the largest disadvantage or weakness of off-site reprocessing. If you have to maintain a quality system, water treatment plant, reprocessing equipment and employ staff on-site anyway, why not keep the whole CSSD on-site?

A possible advantage of sending remaining surgical instruments off-site is that it frees up space to allow for a compliant endoscope reprocessing space. I have seen a large number of hospitals where endoscope reprocessing has drawn the short straw in the allocation of floor space. This makes it more or less impossible for those facilities to attain compliance with AS/NZS 4187:2014

9. Loan kits

Orthopaedic surgery, particularly, generates enormous amounts of soiled RMDs for reprocessing. Your hospital staff spend inordinate hours organising:

• Delivery

• Check-in

• Reprocessing

• Internal delivery to theatre

• Disinfection

• Check-out

• Invoicing

• Return

of these loan kits to and from the manufacturers, often in cramped, undersized areas. Many hospitals have stacks of loan set road cases along corridors, impeding the flow of beds, trolleys and people. Doing all of this off-site brings with it some advantages:

• A single point of delivery and return for loan kits

• Reduction in hospital storage space requirements

• Better utilisation of RFID tunnels and other check-in equipment

10. Existing or new build?

Like converting an existing building into a hospital, converting an existing industrial building into an off-site reprocessing centre is not recommended. There’s a great deal of equipment and services that is difficult to retrofit into an existing building. An example of this equipment is trolley washers that are best installed over a pit.

Conclusion

There’s a lot to digest and work through if you’re considering centralising your reprocessing departments onto one site. There’s multiple interacting advantages and disadvantages, and the final choice will be dependent on each provider’s individual situation.

The changes to compliance requirements as a result of AS/NZS 4187:2014 and the commission’s advisory AS18/07 spurred some providers to look carefully at centralisation. Those facilities that have started to upgrade all the on-site CSSDs, then centralisation is clearly not applicable – for now. The European experience demonstrates that for some providers there is value in centralising without the additional motivation of regulatory change.

A small number of Australian healthcare providers are well underway with pilot projects, and Sterequip is offering outsourced services with the same model. The European examples show that it works well as long as planning, design and roll-out is carefully executed.