Journal of Perioperative Practice PROCUREMENT GUIDE March 2014

Journal of Perioperative Practice

PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 01423 881300 www.afpp.org.uk

01423 881300 www.afpp.org.uk

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

Contents

Welcome to your March 2014 Guide 04

The implementation of a Da Vinci Surgical System at The Royal Wolverhampton NHS Trust

14

Decontamination of reusable surgical instruments: how up to date are you?

15

Endoscope decontamination

17

How to save 3% of your perioperative supply budget

Journal of Perioperative Practice Procurement Guide information In print within the AfPP Journal of Perioperative Practice covering national AfPP members, but also with a dedicated print and e-distribution to supplies and purchasing managers.

Key Sectors: NHS Supply Chain, Independent Hospitals, Higher Education.

Medical Device Companies.

Published 6 times a year we will focus on procurement issues in every edition as well as specialist subjects which for the following year include:

Contact Information: May 2014 Infection Prevention July 2014 Day Surgery September 2014 Airway Management November 2014 Safety January 2015 Recovery

Advertising, Sponsorship & Partner Packages.

Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: francesmurphy60@yahoo.com Editorial Chris Wiles Head of Publishing / Editorial AfPP T: 01423 882950 E: chris.wiles@afpp.org.uk

PR & press material.

All press releases welcome and we will feature as many as we can in each issue, all press releases need to be submitted to: Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: francesmurphy60@yahoo.com

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

Robotics

The implementation of a Da Vinci Surgical System at The Royal Wolverhampton NHS Trust For many years technological advances in laparoscopic surgery have been revolutionary in the world of minimally invasive surgery. Advances in video imaging, endoscope technology and surgical techniques have made successful endoscopic surgery possible (Mack 2001). Robotic surgery is currently growing in popularity within UK hospitals, particularly in specialities such as urology, gynaecology and colorectal.

Currently there are approximately 40 Da Vinci surgical robots (DVSR) being utilised in the UK and approximately 11 trusts with a gynaecology robotic programme in place. This article we will be discussing the implementation of the DVSR at The Royal Wolverhampton NHS Trust (RWT).

There have been constant advances within the surgical robot field since their inception in 1985. The Puma 560 was a robot that was first used to improve precision when taking neurosurgical biopsies (Lanfranco et al 2004). The vision for these surgical robots was for them to enhance and extend a surgeon’s abilities beyond normal laparoscopic surgery.

The DVSR has been well publicised over recent years, there are advantages and patient benefits from utilising the DVSR when compared to open surgery or conventional laparoscopic surgery. Over the last few years many surgeons who have minimal advanced laparoscopic skills can convert their laparotomy cases to minimally invasive surgery utilising the DVSR (Holloway et al 2009).

The DVSR is well known worldwide when discussing robotic surgery. It was developed in 1980 by Intuitive Surgical Inc through research that was carried out by the Defense

The DVSR has been well publicised over recent years, there are advantages and patient benefits from utilising the DVSR when compared to open surgery or conventional laparoscopic surgery.

Advanced Research Projects Agency (DARPA) in the USA. Through funding from DARPA substantial advances were made for telepresence surgical systems which had major influences on the design of the first DVSR. This was then approved for the use in laparoscopic surgery by the Food and Drug Administration Agency (FDA) USA in July 2000. Since the introduction of the first DVSR in 1995 Intuitive Surgical have updated the robot three times which gives an indication of how rapidly robotic surgery is evolving.

Advantages of the Da Vinci system Enhanced visualisation enables identification of tissue planes and blood vessels more easily l Less tissue trauma l Reduced blood loss l Reduced pain l Fewer postoperative complications l Shorter hospital stays. l

(Zender and Thell 2010)

Disadvantages of the Da Vinci system

Initial setup and subsequent maintenance costs can be high l The large size of the robot and the console sometimes make guiding them to their designated place difficult l Longer operative times due to the surgeons and the staff developing their role within robotic surgery l The inability to make informed decisions based on all of the patient factors l Motivation for staff that are not technically minded. l

The Da Vinci surgical system

The DVSR system has been designed to enhance the surgeon’s capabilities by using the most up to date technology (Intuitive Surgical Inc 2013).

The system consists of three sections: The patient cart: this is guided by a member of staff adjacent to the patient. It contains four robotic arms, three that can hold a variety of instruments such as scissors, needle holders and graspers whilst the fourth arm holds the 3D camera in place.

These robotic arms are attached to the ports inserted into the patient’s abdomen and controlled by the surgeon when he is at the surgeon’s console. l The surgeon’s master console: this is ergonomically designed to allow the surgeon to sit and operate once the robot has been docked and the robotic arms are in place.

The arms are utilised using a combination of hand controls and foot pedals.

When looking through the l

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

master console the surgeon will have a highly magnified 3D view of the operative site. l The vision system: this delivers high resolution video feed with a magnified view of tissue planes and anatomy to the surgeon located at the console. l Endowrist forceps: these are instruments that attach to the robotic arms. They have been designed to mimic the human wrist but can provide greater motion than the human hand.

The endowrist forceps provide the surgeon with enhanced dexterity and better control by being able to have seven degrees of freedom, 90 degrees of articulation, motion scaling and tremor reduction (Intuitive Surgical 2013).

Robotics

Robotic programme development

In December 2010 The Royal Wolverhampton NHS Trust took a major step towards the world of robotic surgery when they decided to lease the Da Vinci surgical robot system. This was an exciting time for the RWT as it was in a very privileged position taking part in such a new innovation; the first of its kind within the West Midlands.

The RWT’s values are to ensure that: l Patients are at the centre of all that we do l We will always be innovative l We create an environment in which people thrive l We empower people to explore new ideas.

As well as improving patient outcomes as a whole the RWT want to ensure that our patients are receiving the most up to date care. Each speciality had clinical reasons why the Da Vinci robot could improve their patient outcomes and open up new possibilities. Mr Cooke, Consultant Urologist and Prostate Cancer Specialist, from RWT was one of the key people involved in the implementation of the Da Vinci surgical system. In the December 2011 edition of the Wolverhampton Prostate Cancer newsletter he discussed that this was an exciting time for RWT and

DATE

ACTION

March 2009

Clinicians had a meeting to discuss the Da Vinci surgical system

June 2009

Intuitive Surgical visited the trust to present the Da Vinci surgical system

November 2009

Clinicians organised a visit to a London hospital with an established robotic program

November 2010

Business case was put forward to the trust board with input from the Quality and Safety Group

December 2010

The Da Vinci surgical system arrived at the trust

January 2011

A Da Vinci working group was established

January 2011

The urology team including consultant surgeons, anaesthetists and theatre staff commenced their extensive team training

February 2011

An implementation plan for the Da Vinci surgical system was submitted to RWH Quality and Safety Group

March 2011

The trust completed their first surgical robotic case, Mr Cooke along with his urology team and a proctor present performed their first prostatectomy

April 2011

The urology team were winners of the innovation award at the Royal Awards

May 2011

The gynaecology team including oncology and urogynaecology attended Paris for their team training

July 2011

The oncology gynaecology robotic team performed their first robotic bilateral oophorectomy with a proctor present

February 2012

The urology team were awarded a preceptorship in robotic surgery from the Urology Foundation and travel to Nashville

June 2013

The gynaecology robotic team were invited to present at the Society of European Robotic Gynaecological Surgery (SERGS) conference in London 2013

Nov 2013

The gynaecology robotic team were invited to present at the SERGS conference in Essen Germany

Dec 2013

The gynaecology robotic team were nominated for a Royal Award

by Mr El-Ghobashy, Consultant Oncologist at the RWT

Table 1 A timeline to show the implementation process at RWT

that utilising the Da Vinci robot would allow us to have access to a whole new world in technical innovation and accuracy. Mr David Loughton CBE Chief Executive of RWH supported this by stating “the benefits of using this instrumentation are huge, patients operated on using this method can expect less scaring, a shorter hospital stay and far less risk of infection” (NHS local 2011).

As shown in the timeline in Table 1 the procurement of a Da Vinci surgical system can take some time. In June 2009 a representative from Intuitive Surgical came to the Trust and presented the system to invited clinicians and managers who were keen to see the system in action. A visit to a London hospital with an established robotic programme was

organised in November 2009.

This visit is seen as a key moment in the procurement of the DVSR at the RWT as it was here that the clinicians saw the robot in action. A clear vision could then be seen as to how the Da Vinci robot could be utilised at the RWT within the different specialities.

Development of the robotics program after the London visit

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

Robotics Camera arm manipulation Suturing l Emergency undocking l Undraping and the shutdown of the system l Troubleshooting.

Once the training had been completed the surgeons and their teams were able to conduct robotic surgery under the supervision of a proctor until both the surgeon and the proctor were in agreement that they could be signed off.

took time. In November 2010 a business case was put together and presented to the Trust Board and the Patient Safety Group within the Trust. When developing a business plan for a robotic program the items on the agenda to consider are direct costs to the trust, materials needed, staff training and theatre room modifications (Palmer et al 2012).

Discussions took place about the clinical reasons why the robot would be of benefit to the Trust as well as the financial benefits/ implications and funding. Shortly after the meeting the RWT made the decision to lease the robot and the DVSR arrived in the trust in December 2010.

l l

As well as robotic team training, Intuitive Surgical provides online training modules through the Da Vinci surgery community website. Through this community staff have access to online surgical videos, up to date research, support materials, online conferences and seminars.

Intuitive Surgical also provide onsite training where a mock theatre is devised so that the theatre team can be more prepared and feel more confident before their first robotic case.

To implement a robotic program a multi-disciplinary team should be assembled as soon as possible (Zender and Thell 2010). A Da Vinci working group was established in January 2011 in order to identify an implementation plan for the system within theatres. An implementation plan was drawn up by group manager, theatres/ ICCU service group and clinical leads for each speciality which was submitted to the Quality and Safety Group.

A multidisciplinary Robotic Surgery User Group whose membership included, directorate managers, surgeons, anaesthetists, governance personnel, theatre sisters and Intuitive Surgical representatives was set up and this group focused on the following safety elements:

Surgeon, proctorship and theatre team training

The RWT understood that staff education was the key to a successful robotics program, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (2007) supports this as they feel it is a necessity that staff undergo training before the surgical robot is used clinically.

In January 2011 the urology and colorectal team were the first to complete the extensive training at an education facility in Paris

and the gynaecology robotic team followed in May 2011. Staff education is key to implementing a successful robotic program as well as providing patients with a gold standard of care. Training in another theatre setting can have a real positive effect on the team; it gives them an opportunity to work away from their normal theatre settings so that new technical skills can be acquired for safety and efficiency during robotic surgery (Martin et al 2004).

The preparation of the robotic system required team members to have sufficient training so that they could set up, maintain and troubleshoot at any time allowing the surgeon to focus on the patient at all times. The technical aspects of the robot

system can be very complex so they need to be broken down into understandable chunks. It is a necessity that staff undergo training before the surgical robot is utilised clinically, it is well documented that robotic surgery can be quite complex both mechanically and electrically (SAGES 2007).

The training agenda in Paris covered: l Moving and draping the system l Manipulation of the surgical arms l An overview of accessories and decontamination l Port placement philosophy l Installation techniques l Starting dissection l Instrumentation changes

In February 2011 a meeting was arranged to discuss the implementation plan for the surgical robot. It was agreed that urology would implement the surgical system first utilising it for cases such as robotic assisted prostatectomy and nephrectomy. Once the urology robotic team became established a plan would be put into place to extend robotic surgery to other specialities; gynaecology, colorectal, cardiac and head and neck. Within the implementation meeting the following quality and safety measures were discussed: Patient selection criteria It was agreed that all robotic surgical patients were to be seen personally by the surgeon so they could select those who fit the criteria for robotic surgery.

Discussions included informing the patients of all of the options available as well as discussions on consent. The patients were informed that they would be among the first to undergo robot assisted surgery within the RWT and all of the above discussions as well as the surgeons training and proctorship would be documented in the patients’ notes.

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Clinical Audit Progress reviews for robotic surgery and clinical audits are at the heart of clinical governance and should be reviewed regularly.

They provide a method of reviewing the quality of care we are giving to our patients whilst highlighting any need for improvements (NICE 2002). Each speciality will carry out audits and submit them at each directorate meeting and to the Trust Quality and Safety Group after a nominated amount of time.

Decontamination The RWT sterile services provider Synergy was to be responsible for the decontamination of the Da Vinci instrumentation and equipment. Intuitive Surgical would provide the decontamination instructions to the managers. Specialist decontamination equipment was needed in order to sterilise the robotic equipment. Synergy staff also had to have specific training

Robotics for this as it was a different process from their normal routine.

Postoperative guidelines It was discussed that the operating clinician would make themselves available out of hours via mobile if any postoperative complications were identified; this would be in addition to the standard on call consultant cover that was provided. Consultants and junior doctors would be educated on early identification of postoperative complications and an early recognition document had been produced to support this.

Evolving roles and responsibilities The role of the scrub nurse and the theatre support assistants, acting as the patient’s protector, is expanded due to the robot being so near to the patient and that the surgeon is not at the patient’s side for the entire procedure. The added responsibility is large as

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Robotics

A breakdown of the robotic surgery currently being performed at the RWT

Urology procedures

Gynaecology procedures

Cardiac Procedures

Prostatectomy

Robotic assisted total hysterectomy

Mitral valve replacement

Pyeloplasty

Lymph node dissections

Nephrectomy

Radical hysterectomy

Partial nephrectomy

Sacrohysteropexy

Cystectomy

Sacrocolpopexy

it often falls to the nursing staff and the theatre support staff to make sure that the robotic system is in working order and that, as a team, they should be constantly observing proceedings intraoperatively so that any issues can be brought to the attention of the surgeon and the assistant surgeon.

The preparation of the robotic system requires team members to have sufficient training so that they can set up, maintain and troubleshoot at any time, allowing the surgeon to focus on the patient at all times. The technical aspects of the robot system can be very complex so they need to be broken down into understandable chunks. The theatre staff ensure that all of the instruments and technology are utilised properly and cared for, which is a great responsibility.

Equipment, as always, is expensive so it has to be handled in the correct way to minimise damage and to reduce repair or replacement costs.

In March 2011 the urology team completed their first robotic prostatectomy which was a great success. They had organised a dress rehearsal with a dummy in theatre the day before so that when they came to operating the following day all of the training was fresh in their minds, which resulted in the case running smoothly. In April 2011 the urology robotic team were winners of the Innovation Award at the Royal Awards for implementing the Da Vinci surgical robotic system successfully whilst also delivering clinical benefits to their patients.

Part of the gynaecology robotic team consisting of

senior consultant oncologists, consultants from urogynaecology and a theatre sister attended extensive training sessions in Paris in May 2011. When they returned all of the training/ information was cascaded down to the whole team. The senior members of staff had a meeting in order to discuss how we could all have a clear direction of where we were heading, what the expectations were and how we were going to incorporate the Da Vinci robot within our teams.

In July 2011 the gynaecology robotic team performed their first robotic bilateral oophorectomy with the support of the urology robotic team and the Intuitive Surgical representatives that were always available to offer their experience and knowledge on the Da Vinci system. The surgery was successful and the team have gone from strength to strength since their first robotic case.

The gynaecology robotic team were invited to London to present

The surgery was successful and the team have gone from strength to strength since their first robotic case.

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at the Society of European Robotic Gynaecological Surgery (SERGS) Annual Conference in June 2013. The subject of the presentation was ‘developing a robotic team in Gynaecology from a nursing perspective’. The presentation was very successful; we were very grateful and proud as we had had the opportunity to share information with nursing staff from all over Europe and to showcase what we had learned and achieved to date. In November 2013 the gynaecology robotic team were invited again to present at the May 2014 SERGS conference in Essen Germany something that we are very excited about; the subject will be ‘the need for standards and guidelines in robotic surgery from a nursing perspective’. This is a subject we are very passionate about as we are continuously striving to improve patient care and patient experiences.

Conclusion

Developing a successful robotic team can be quite intense; it requires a big team effort and lots of preparation from a team of dedicated staff. Support given by forward thinking

Robotics

managers, clinicians and theatre staff ensures the success of an implemented robotic program within trusts worldwide. All of the management teams and robotic teams working within the RWT have strived continuously to improve patient care by ensuring that high standards are maintained and that patient safety is always at the forefront of whatever tasks are undertaken.

It is important that the robotic program within the trust is reviewed on a regular basis so that improvements can be made to maximise efficiency. Continual development in the world of robotic surgery will transform the surgical care that we can provide for our patients whilst also ensuring that the role of every team evolves into something that can revolutionise every patient’s robotic surgical journey.

Acknowledgments The author wishes to thank all of the hardworking multidisciplinary robotic teams within the RWT whose dedication and contributions to robotic surgery have resulted in safe and successful robotic surgery being implemented and performed within the RWT.

References Holloway RW, Patel SD, Ahmad S 2009 Robotic surgery in gynaecology Annals of Surgery 98 (2) 96-109 Intuitive Surgical Inc 2013 History of Da Vinci [Online] Available at: http://www.intuitivesurgical.com/ company/history/ [Accessed 03 January 2014] Lanfranco A, Castellanos A, Desai J, Meyers W 2004 Robotic surgery a current perspective Annals of Surgery 239 (1) 14-21

Palmer K, Orvieto M, Rocco B, Patel V 2012 Launching a successful robotic program Springer [Online] Available at: http://link.springer.com/ chapter/10.1007%2F978-184882-800-1_2 [Accessed 30 December 2013] Society of Gastrointestinal and Endoscopic Surgeons 2007 A Consensus Document on Robotic Surgery [Online] Available at: http://www.sages. org/publications/guidelines/ consensus-document-roboticsurgery/ [Accessed 30 December 2013]

Mack M 2001 Minimal invasive and robotic surgery The Journal of the American Medical Association 285 (5) 568-572 Martin S, Murz Y, Darzi A 2004 Robotic assisted surgery British Journal of Perioperative Nursing 14 (1) 36-38 NHS LOCAL 2011 Robot to aid surgeons at Wolverhampton Hospital [Online] Available at: http://www.nhslocal.nhs. uk/story/robot-aid-surgeonswolverhampton-hospital [Accessed 05 January 2014]

Zender J, Thell C 2010 Developing a successful robotic surgery program in a rural hospital AORN Journal 92 (1) 72-82 Dezita Taylor Dip HE, BSc Senior Operating Department Practitioner, The Royal Wolverhampton NHS Trust

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

Instruments

Decontamination of reusable surgical instruments: how up to date are you?

Efficient and effective decontamination of medical devices is required to conform to a series of local trust, United Kingdom (UK) European (EU) and International (ISO) standards and guidelines.

One of the main drivers behind efficient and effective decontamination of surgical instrumentation was highlighted

by Creuztfeldt Jakob Disease (CJD) outbreaks over the past two decades (NICE 2006). This led to updated Department of Health (DH) standards and guidance surrounding decontamination of flexible endoscopes (CFPP 01-06 2013 England), surgical instrumentation (CFPP 0101 2013 England) dental instrumentation (HTM 01-05) and hospital linen (CFPP 01-04 2013 England), yet this list is not exhaustive. This also brings in line the upcoming change to flexible endoscope department auditing (JAG 2013) which is currently under consultation.

Alternatively there is a section within the newly revised AfPP Perioperative Audit Tool (previously the Risk and Quality Management System) that covers decontamination of surgical instrumentation and flexible endoscopes (http://www.afpp. org.uk/books-journals/books/ book-137) As you are well aware the UK is separated into national regions, with a different Department of Health for each region, England, Scotland, Wales and Northern Ireland. Therefore following national guidance may appear ever more confusing, however many of the principles

The current guidance directs the operational workforce not only towards recommended decontamination processes but also to evidence based research currently being undertaken, for example ‘wet versus dry instrumentation’, ‘prion detection on surgical instrumentation’, ‘decontamination of Transoesophageal Echocardiography (TOE) probes and anaesthetic laryngoscopes’.

remain similar in context. The current guidance directs the operational workforce not only towards recommended decontamination processes but also to evidence based research currently being undertaken, for example ‘wet versus dry instrumentation’, ‘prion detection on surgical instrumentation’, ‘decontamination of Transoesophageal Echocardiography (TOE) probes and anaesthetic laryngoscopes’.

In response to this, in 2012, AfPP joined forces with many like-minded professional healthcare related bodies to form the Professional Expert Communications Forum: Decontamination of medical devices (http://www. afpp.org.uk/communities/ deconforum) providing a UK forum for professional expert organisations to work together and communicate on relevant issues to influence and advise on policies, procedures and best practice surrounding decontamination of medical devices. Organisations currently involved in this forum are: 1. Association of British Healthcare Industries (ABHI) 2. Association for

Perioperative Practice

(AfPP) 3. British Society of

Gastroenterology (BSG) 4. Central Sterilising Club

(CSC) 5. Healthcare Infection

Society (HIS) 6. Institute of

Decontamination

Sciences (IDSc) 7. Infection Prevention

Society (IPS) 8. Institute of Healthcare

Engineering & Estates Management (IHEEM): Decontamination Technical Platform (DTP) 9. Medicines and Healthcare

products Regulatory

Agency (MHRA) 10. Royal College of Nursing

(RCN) However, even with the support and advice from expert groups and the growing body of knowledge through education and research there are still many pressures on decontamination staff. These lead to human error, lack of compliance with local and national policies, and confrontation between operating theatre staff and sterile service staff due to high demands for a fast turnover of equipment to meet service demands.

The forum has therefore put together a list of links to some of the relevant guidelines that are required to conform to the different regions of the UK, and may be updated and amended regularly to help support staff. It is your department’s responsibility to keep up to date with the most recent editions.

In summary, it is imperative that as healthcare professionals we all bear in mind that as medicine and surgery evolve, the surgical instrumentation required to perform these procedures becomes more advanced and more technical.

Therefore the decontamination processes required to render the instrumentation free from contamination, and safe to be reused, also becomes more technical, specialised and advanced.

As perioperative practitioners

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

at the forefront of patient safety and patient care, we all need to keep abreast of current advances and the related standards that govern these decontamination processes.

We strongly believe that we are an inter-disciplined multiprofessional team, and by ‘team’ it is imperative that we include sterile service departments and be aware of each other’s roles and responsibilities. This should include regular inter-departmental joint training and department visits to ensure we are all aware of current changes, ensuring a more efficient and effective service is provided throughout the patient’s holistic journey.

So maybe you need to ask yourself; decontamination of reusable surgical instruments: how up to date are you?

References Department of Health 2013 Choice Framework for Local Policy and Procedures 01-01 – Management and decontamination of surgical instruments (medical devices) used in acute care. Part A: the formulation of local policy and choices manual Version: 1.0: England [online] Available from: https://www.gov.uk/government/ publications/management-anddecontamination-of-surgicalinstruments-used-in-acute-care [Accessed January 2014] Department of Health 2013 Choice Framework for Local Policy and Procedures 01-04 – Decontamination of linen for health and social care manual Version: 1.0: England [online] Available from https://www.gov. uk/government/publications/ decontamination-of-linen-forhealth-and-social-care [Accessed January 2014] Department of Health 2013 Health Technical Memorandum 01-05: Decontamination in primary care dental practices https://www.gov.uk/government/ publications/decontaminationin-primary-care-dental-practices [Accessed January 2014] Department of Health 2013 Choice Framework for local Policy and Procedures

Instruments 01-06 –Decontamination of flexible endoscopes: Operational management [online] Available from: https:// www.gov.uk/government/ publications/management-anddecontamination-of-flexibleendoscopes [Accessed January 2014] Joint Advisory Group 2013 JAG Accreditation System & Endoscopy Global Rating Scale (GRS) [online] Available from: https://www.jagaccreditation.org/ default.aspx [Accessed January 2014] National Institute for Health and Care Excellence 2006 Patient safety and reduction of risk of transmission of CreutzfeldtJakob disease (CJD) via interventional procedures (IPG196) [online] Available from: http://www.nice.org.uk/cjd [Accessed January 2014]

Angela Cobbold PGCE, BSc (Hons), Dip He, ASP, ODP Senior Lecturer, Acting Course Group Leader Allied Health and Medicine, Course Leader FdSc Decontamination Sciences/ Medical Device Decontamination, Course Leader MCh Minimally Invasive and Robotic Surgery, Anglia Ruskin University, Chelmsford Sue Lord PG Dip, BA Education, RGN, RNT, ASP Head of Department, Allied Health and Medicine, Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford

Endoscope decontamination The MHRA has published a poster ‘Top Ten Tips on Endoscope Decontamination’ This includes: 1.

Quality 2.

Staff training 3.

Compatibility 4.

Identification 5.

Channel connection 6.

Manual cleaning 7.

Chemical compatibility 8.

Process validation 9.

Preventative maintenance 10.

Incident reporting Download a copy of the poster from: www.mhra.gov.uk/Publications/ Postersandleaflets/CON2022584

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Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

Procurement

How to save 3% of your perioperative supply budget Healthcare organisations need to make significant savings and control the limited budget while providing for efficient patient throughput. Literature is available in the USA, but there is a complete lack of research on supply chain savings in hospitals in Ireland and internationally. While there is a need to control costs in healthcare, there is an opportunity to make significant savings in the supply chain in theatres through the use of effective supply chain management (SCM) (DeJohn 2008). This research focused on cost reduction in the perioperative supply chain in this four theatre orthopaedic hospital as part of a dissertation of an MSc. This study was performed using action research. It is research ‘with’ people versus research ‘on’ them (Coghlan 2010). It is accepted that by involving participants in the change process that this increases the opportunity that permanent change may result. It is used in a wide range of areas including, group dynamics, organisational change and nursing. The implementation of SCM principles to the operating theatre department is a planned intervention for a real problem.

Discussion

The tangible output from this project was the cost saving in the region of €940,000 over a 12 month period.

The implementation of this methodology has confirmed that significant cost savings can be realised with minimal input.

One off costs for the reduction of stock held in the department resulted in €30,000 or a 25% stock reduction in line with other studies.

It has proved that an experienced clinical nurse manager can determine how cost savings can be made. The saving from the

The tangible output from this project was the cost saving in the region of €940,000 over a 12 month period.

introduction of custom packs in the department was €140,000 with year on year savings in the region of €140,000 per year and this ensures a more efficient operating department performing more procedures for less. This increases the economies of scale per procedure. Nursing labour savings of thirty minutes per case resulted from using custom packs mirroring Boyds (2004) experience with custom pack implementation. This is based on taking 15 minutes per case to collect all consumables and 15 minutes to open them.

Taking cognisance that this is an average of minor and major cases it can take up to 1.5 hours to set up for some complex procedures if all elements are separate. This saving equates to €44,600 of nursing time. This is a huge driver for the efficient use of trained perioperative nurses as it resulted in more expedient patient positioning and earlier surgical starts.

The value of excess stock returned was difficult to capture due to the lack of traceability for some items but it is in the region of €40,000. The use of

information systems needs to be vastly improved and would have led to better analysis of the materials database. Industry would not function without good information systems to manage their supply chain and in the future this will be led by GS1 barcoding technology. The study found that staff involved in the operating theatre supply chain need to be educated on SCM methods as supported

by Davis (2005) and Patterson (2009) who cite the importance of developing clinical champions in the perioperative supply chain.

However, we must not forget that nurses/managers must perform their clinical work and be supported by fully functional ordering systems that don’t divert managers to manually order and then fill in computer database ordering.

The implementation of this methodology in the perioperative setting is unique in Ireland.

Crucially, the theatre department has driven the change from within, as it dealt with a real life issue which is apparent to no-one except perioperative nurses who work in this high cost area. There is a culture change in the department as staff now know the cost of the all supplies. This has empowered nurses to make decisions about which expensive supplies to open for each case, as in the past cost may not have been an issue. Nurses also appreciate the efficiency of custom packs, due to time pressure to set up for the next case immediately once the previous patient has left their theatre. Medical staff also make decisions based on value for money and decide which products they want to use.

The introduction of SCM as a method of saving money is

Journal of Perioperative Practice l PROCUREMENT GUIDE March 2014 Volume 03 Issue 01 www.afpp.org.uk

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crucial. Cost savings are a major result, as inventory reduction and the improved availability of standardized consumable products and instrumentation incur considerable savings (Park & Dickerson 2009, Feistritzer & Keck 2000). A streamlined perioperative supply chain allows for increased efficiency for all staff. This showcases a framework for other theatres to follow in restructuring their supply chain; leading to a reduction in nursing time spent in preparation for surgery; scrub nurse preparation of instruments immediately prior to surgery and in the turnover of the theatre.

The time saved results in adding an additional major procedure to each operating list, thus increasing the hospitals efficiency and dealing with waiting lists.

References Boyd D 2004 Custom procedure packs - the Regina experience Canadian Operating Room Nursing Journal 22 (2) 28-34

The savings described were achieved on a cost neutral basis.

No extra human resources were required to implement this system, but after the system was set up it was staffed by a stores person. It is important to utilise the clinical knowledge and skills of nurses to develop and lead this type of project as it will result in cost savings in any operating theatre or hospital it is introduced to. This study is for international publication. The answers for saving the health service lie with the front line staff, but to be heard is the hardest thing. “Seek first to understand, then to be understood” Stephen Covey.

Procurement

A streamlined perioperative supply chain allows for increased efficiency for all staff. This showcases a framework for other theatres to follow in restructuring their supply chain; leading to a reduction in nursing time spent in preparation for surgery; scrub nurse preparation of instruments immediately prior to surgery and in the turnover of the theatre.

Have you any ‘New Products’ to launch or ‘Established Products’ you wish to push to the forefront of the ‘NHS Supply Chain & Private Sector’?

Coghlan D, Brannick T 2005 Doing Action Research in your own Organisation 2nd Ed London, Sage Publications Coghlan D 2007 Insider action research: opportunities and challenges Management Research News 30 (5) 335-343 Davis E 2005 Educating perioperative managers about materials and financial management Association of periOperative Registered Nurses Journal 81 (4) 801-812 DeJohn P 2008 Keeping ORs’ freight costs in bounds OR Manager 24 (5) 17-18

Sandra Morton MSc Health Service Management, Trinity College Dublin Sandra, a nurse, saved her hospital a million a year, from a budget of €30 million, by applying more rational supply chain management policies. This is an executive summary of her work for an MSc in Health Services Management, Trinity College Dublin.

Feistritzer N, Keck B 2000 Perioperative supply chain management Seminars for Nurse Managers 8 (3) 151-157 Park K, Dickerson C 2009 Can efficient supply management in the operating room save millions? Current Opinion in Anaesthesiology 22 242-248.

Patterson P 2009 Getting the staffs buy-in for lean OR Manager 25 (5) 13-14

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