How often do you experience stress or anxiety the day before a busy procedural schedule? Have you ever wondered if you have enough colonoscopes or if any devices have been sent out for service? If so, has loaner equipment arrived? Is the department efficiently staffed to manage the patients, doctors and equipment?
How often do you think about the number of assets in your department? Assets are all the endoscopes needed to provide safe patient care. How do you know you have enough assets to support the procedures on your schedule? If endoscopy professionals across the country were asked if their department has enough equipment, many would say they do not. GI procedures are increasing, and according to Paone (2024), the leading causes of higher volumes are a backlog of patients who delayed procedures during the pandemic, a new recommendation for colorectal cancer screening to begin at the age of 45, and an aging population.
How does a department get ahead and ensure enough equipment is available to accommodate procedural volume? Before we get to the “how,” let’s review why it is important to have sufficient inventory.
Form and Function
The Centers for Medicare & Medicaid Services (CMS) requires hospitals to ensure supplies and equipment are maintained to an acceptable level of safety and quality for patient use (Centers for Medicare & Medicaid Services, Department of Health and Human Services, 2017). These guidelines are based on a federal statute called the Code of Federal Regulation (CFR), which governs areas in healthcare that pertain to patient care. CMS and other accrediting agencies conduct surveys to ensure healthcare facilities effectively meet required standards and regulations.
The CFR spells out standards and expectations for how facilities should function to keep patients safe, stating that hospital have three responsibilities: 1) Facilities should have enough supplies on hand to meet day-to-day needs as well as what would likely be needed in the event of an emergency; 2) Facilities should have adequate provisions to support and maintain supplies; 3) Facilities should ensure supplies are stored in a manner to protect them from theft, contamination, damage and deterioration. This responsibility applies to equipment too (Centers for Medicare & Medicaid Services, Department of Health and Human Services, 2017).
When we think about how to ensure equipment is safe for patient use, it is good to think about it from a quality-management perspective. Quality management is an ongoing process — a series of actions or steps taken in order to achieve a particular end (Seelbach & Brannan, 2023). Understanding how equipment is used is known as asset utilization, and it’s part of a quality-management process. Under-standing and implementing the quality-management process is important in the perioperative space because things change very frequently. For example, priorities shift, procedure volumes increase and decrease, and employees come and go. Using a quality-management approach can provide insight into needed changes to your inventory that will positively impact your department and facility. Hopefully, by using a quality-management strategy, the frequency and severity of asset damage will change as well.
There are various types of flexible endoscope models that are used in the perioperative space. Specific situations, such as opening a new department or upgrading to a new generation of equipment, require assessment of how much inventory is needed. Over time, that initial amount can change. Perhaps you started with enough, but how do you determine when to add more?
One approach is to consider how long it takes to clean, inspect, disinfect or sterilize, and dry items, along with the types of reprocessing equipment and specific cycle times being used. Another approach is to evaluate the physical size of your department. Do you have enough space to manage all flexible endoscopes in your inventory? Is the layout and flow conducive and efficient? A third approach is to determine the number of staff needed to manage inventory. How many people are needed to turn around flexible endoscopes safely in a timely manner? Many times, these factors are used to determine the amount of inventory needed initially but may not be used to determine if inventory is sufficient on an ongoing basis.
How many assets do you really need? According to Philip Doyle, Olympus executive director of marketing, “Olympus recommends that each scope only get around 300 uses per scope per year.” (TechNation, 2023). Without the right number and mix of equipment, procedural turnover times can decrease, which can impact efficiency and other factors such as staff overtime. Understanding not only how much inventory is needed overall but how much of each type of flexible endoscope model is needed can be challenging.
Determining environment-of-care requirements in departments such as sterile processing and endoscopy is important. One of the biggest challenges facilities may have is inventory storage. Having adequate space is vital. As procedural volumes increase, it is important to evaluate space in the department to ensure there is enough room to store an increase in inventory. It is also important to evaluate the types of containers needed to transport — and cabinets to store — flexible endoscopes. For example, are transport containers designed to support flexible endoscopes from shifting and being damaged? Do you have the right type of cabinets to properly isolate and secure flexible endoscopes? Is storage space organized and easy to navigate?
Evaluating workspace is another factor to consider. Having an adequate setup in the decontamination and reprocessing area is critical to ensure efficient and effective cleaning. Some flexible endoscopes may require extended cleaning or soak time, which can tie up a sink and create a backlog. When space is limited, it can be easy to stack flexible endoscopes on top of each other, but this can potentially damage the endoscopes and create the need for replacements.
Routinely evaluating departmental environment provides insight into continuous improvement measures. When procedural volume is high, more time is needed to sufficiently clean everything. Evaluating the specific types of cleaning cycles being used can be very insightful when determining whether inventory is sufficient. Leak testing, manual cleaning, inspection, HLD/sterilization and drying all take time. The longer the reprocessing time, the more inventory you may need to support procedural volume. Always refer to the manufacturer’s instructions for use (IFU) for cleaning requirements for each flexible endoscope model to determine what cleaning steps should be used.
Part of implementing quality-management processes requires evaluating inventory. It can be beneficial to consider the impact of insufficient inventory on individual departments, the facility as a whole, and the patients being cared for. It can be challenging to turn equipment over quickly. This type of pressure can increase staff stress and potentially lead to missing an important step — or worse, cutting corners. Increased wear and tear on inventory from repetitive use and reprocessing can result in increased damage and repairs and result in equipment not being patient-ready when needed. Ultimately, lack of sufficient inventory can lead to the need for bringing in outside equipment (referred to as loaners). Loaner equipment is not an immediate solution. For example, if you have a flexible endoscope that is sent out for repair and a loaner device is needed, most likely you will not receive that device until the next day at the earliest. Once received, the loaner item should be fully reprocessed before it is used, which also takes time.
Nurses Count
Many facilities experience staffing challenges. McKinsey & Company (2022) predicts a potential shortfall of 200,000 to 450,000 registered nurses available for direct patient care by 2025. Staff are crucial to the success of a facility and play a critical role in on-time procedural starts and positive patient outcomes. Once staff are hired, training and education are needed to set teams up for success. Initial training, competency validations and ongoing education are all part of the process. Ensuring departments have the right number of staff to manage inventory for procedural volumes is important.
The last two years have seen updates to guidelines set forth by the AORN and the Association for the Advancement of Medical Instrumentation (AAMI) regarding reprocessing of flexible endoscopes. These updates include a heightened emphasis on visual inspection, cleaning verification, leak testing, drying, and the need for delayed reprocessing.
Visual inspection should be completed for all flexible endoscopes to ensure they are clean, free of damage and functioning as intended (Klacik, 2022; Kyle, 2022). Having enough inventory on hand reduces the need for quick instrument turnover and the potential for missing something during reprocessing. Effective and efficient reprocessing could be impacted because visual inspection, cleaning verification, lengthened leak testing, and drying time all increase the amount of time it takes to reprocess devices.
Without the right number and mix of flexible endoscopes, efficiency of the reprocessing cycle could decrease, resulting in slower procedural turnover times and increases in staff overtime hours. It’s important to evaluate the mix of models in your inventory to ensure you have enough for the different types of procedures being performed. For example, perhaps a doctor prefers to use a pediatric colonoscope for all patients, versus using an adult colonoscope. In that situation, how is inventory impacted? If only pediatric colonoscopes
are being used, adult colonoscopes are being used less. This can increase staff stress from needing to turn the pediatric scope over quickly and could potentially result in delayed availability throughout the day. Even if you have a mix of models, preferences such as this can lead to overutilizing certain models and increased repairs. The challenge is that inventory and volume are not apples-to-apples. Inventory does not always meet procedural volume needs.
A Systematic Approach
An VVV-tracking system can provide insight into how often equipment is being used. Tracking systems may be used to evaluate department productivity, cleaning and assembly times, and the total time needed to complete all reprocessing steps from patient use to patient use. Scanning items into or out of high-level disinfection (HLD) or sterilization can provide insight into procedure volumes. Each time an item goes through HLD or is sterilized, it can be aligned with each time it was used. Year-over-year analysis helps determine overall increases in inventory use and can help determine how to best plan for spikes in procedural volume at specific points in time. For example, some institutions may do more procedures in November and December than other months of the year.
Another approach would be to identify a specific model of flexible endoscope and evaluate its usage month by month. A higher number of procedures performed in a particular month using that specific model may warrant adding more of that type of model to accommodate for higher volume months.
See bar graph below for an example.
Reviewing average uses per day in one month will provide insight into daily average use. Evaluating how many times a specific model was used in the month, the number of that model in inventory, the number of operating days in the month, and the average use per day in that month can tell a story. For example, when evaluating a pediatric colonoscope model, you may determine that two or more uses per day justifies adding another model to your inventory. When
considering the length of the procedure, total reprocessing time, and dry time, adding one or two more of this type of model may be necessary to ensure enough inventory is available.
Every facility will be different. The busiest days are typically when stress is higher and turnover times need to be quicker. It may also be beneficial to drill down further and look at the day or days of the month when more procedures are being done or when a specific doctor works on a specific day. When evaluating asset utilization in this manner, it may be beneficial to have additional equipment to meet the needs of those specific high-volume days. When you analyze usage, you have insight into what items are in demand and what items are needed, which helps prioritize items for budgeting purposes.
See pie chart below for an example.
Routinely evaluating usage can help identify which models you need more of and help you achieve an apples-to-apples comparison between inventory and procedural volume. Right-sizing inventory may not happen quickly, but having data that clearly identifies usage can help support the need for adding inventory and enable you to plan ahead. For example, if procedural volumes are trending upward by 10%, you may consider adding 10% more inventory. Having data to justify the need and to support acquisition drives value for departments, the facility, and the patients served.
Let’s circle back to the quality-management process. Look at the department environment and consider whether it supports the volume and type of equipment being reprocessed, whether you have the right number of staff and can provide needed training and education, and whether you are experiencing inventory-related challenges in one area more than another. Identify, track and trend key performance indicators (KPI) to obtain inventory specific data. For example, KPIs might include reducing the number of HLD or sterilizations for specific models month by month, reducing repair frequency by 20%, or improving on-time procedure starts by 90%.
As you assess your inventory, set measurable indicators to determine if the strategies implemented are successful. Using data analysis to evaluate inventory usage can be beneficial. Increased usage should lead to adding inventory. Make reviewing inventory a routine task and be aware of factors that could lead to needing more equipment, such as adding a new doctor or opening a new room, which leads to increases in volume. Routine evaluation drives changes that will enable you to plan ahead.
Understanding asset utilization can help justify the need to supplement inventory to adequately support increases in procedural volume and help ensure safe patient care.
