Black box CSSD
Are you aware of all cost traps in your hospital?

Are you aware of all CSSD- and OR-related expenses in your hospital?

A healthcare manager has many responsibilities such as strategic planning, staff coordination, allocation of budget and other financial matters. The ultimate aim of the healthcare manager is to ensure the good reputation of the hospital. This requires that the goals of the employees, the budgetary restrictions and the quality of care are aligned and accomplished in an effective and profitable way.

As hospital manager, you try to stay informed about what is going on in your hospital, but you cannot be aware of all processes in detail. Sometimes you would like to know a little bit more about other departments, especially those that are like ‘black boxes’ for you, as your insight into their work is limited. At AESCULAP®, we found that the central sterile supply department (CSSD) tends to be such a ‘black box’.

This situation can be challenging and even expensive for you, because the supply of sterile goods, mainly surgical instruments within the CSSD and operating room (OR), has become highly complex and often acts very inefficiently. 

Let’s talk about some facts

Did you know…

Delays are the most common type of disruption in the OR and the main cause (55.2-57.9%) of delays is equipment failure, including missing or malfunctioning instruments. [1] 

When a new tray has to be ordered during surgery, it takes approximately seven minutes until it arrives in the OR. [2] One minute of OR time costs up to US$ 37, [3] which means that one missing or malfunctioning instrument can cost up to US$ 259 only due to the delay it is causing – in addition there are the costs for the waiting surgeons and nurses.

The instrument utilization rate often is as low as 13% due to overloading of sets. [2] After surgery, all devices should be reprocessed, even if they were not used. 

This causes significant unnecessary costs for health institutions, considering that the total reprocessing costs per instrument exceed US$ 0.51. [2] The reprocessing not only costs money and personnel resources, but also shortens the lifespan of the device. Another problem of overloaded sets is that the rate of broken, and thus unusable, instruments increases with the number per set. [3]

Surgical instruments and sets are often packed in soft wraps, which are prone to pinholes if they are not handled appropriately, for example when being stocked. When pinholes or tears are detected, the whole set is considered as non-sterile and requires reprocessing. On average, 5% of wrapped instrument sets are reprocessed due to tears. [4] Damaged sterile packages can cause OR downtimes and time pressure. Moreover, holes in wraps might appear inconspicuous and could be overlooked. This case represents a serious risk factor for surgical site infections (SSIs).

Instruments that are sterilized insufficiently can lead to SSIs. 2-5% of all patients undergoing surgery develop this kind of infection [5] – for abdominal surgeries, the percentage is even five times as high. [6] A study showed that a sudden increase of the SSI rate in the orthopedics and ophthalmology wards in an NHS hospital in Glasgow could be traced back to poor handling practices in sterilization. [7] In 3% of all SSI cases, this complication leads to the death of a patient. [8] 

On average, a patient suffering from an SSI has to stay in the hospital for ten additional days, causing additional costs of US$ 21,000. [9] SSIs not only damage the hospital’s budget but also its reputation.

In some hospitals, reprocessing cycles do not fulfill basic requirements of regulation, expert guidelines or state-of-the-art reprocessing practices. This is mostly due to the lack of training and leads to mistakes concerning the handling of items: For example, not detecting pitting corrosion on time during care and maintenance leads to a systematic corrosion affecting not only the instrument sets but also the whole reprocessing cycle including the equipment.

Black box CSSD – a potential cost saver

What can be done to solve the problem in the central sterile supply department?

Imagine if your sterile goods management ran smoothly, surgical assets were in good condition, surgical sets were loaded with the correct number of instruments and reprocessed according to high quality standards, and therefore suitable for use in the OR and safe for treating patients. Imagine if you had cost transparency about the whole reprocessing cycle of the most valuable mobile asset in your hospital – the surgical instruments. There would be no complaints or extra costs for delays and interrupted surgeries, no frustration or stressed surgeons and staff, and there would be no prolonged hospitalizations because of SSIs either.

A potential cost saver

AESCULAP®’s extensive analyses of surgical sets in several hospitals have shown that up to 58% of all surgical instruments are not suitable for use in the OR and that the whole process of sterilization offers a large potential for cost-saving. [10]

Discover your saving opportunities

Ensuring the optimal functionality and availability of surgical equipment allows operations to go ahead as planned, avoiding delays, stress and costs. A professional high-quality repair management and a technical service that is reliable and always available when needed can help you to achieve a long lifetime and proper functioning of your instrumentation and thus preserves the value of your surgical sets. Moreover, guaranteeing that functioning devices are always available requires good backup management. This enables surgeries to go ahead as planned while other instruments require repair or maintenance.

Our findings show that set optimization is a highly important and effective measure: Surgical sets are often overloaded. Sets can be optimized and adapted for a variety of surgical procedures. [11] Our experts in Set Consulting found that an average reduction by 22% for existing set structures is possible. [10] Considering that the reprocessing costs for one instrument amount to roughly US$ 0.51, [12] we calculated that the reduction of a 90-piece set to 70 instruments (by 22%) can save costs of up to US$ 408,000 per year. [10]

In many markets, soft wraps are commonly used to pack sterilized surgical instruments but are very prone to pinholes or tears. Damaged packaging cannot guarantee sterility of the instruments and is a high risk for the patient’s health. By contrast, containerization does not only enable safer storage, but also easier handling as containers can be stacked and different lid colors allow for sorting by disciplines. Containers prevent contamination of sets and maintain sterility for at least 360 days. [13] One case study found that – compared to soft wrap packaging – on average US$ 190,000 can be saved per year by containerization. [14]

Well-trained staff is a crucial part of every department. CSSD staff need to know how to handle and maintain surgical sets. For instance, a poor handling praxis of sterilized surgical sets, not according to current guidelines, could lead to an increase of SSIs, which causes additional costs. In addition to that, professionally qualified staff that is able to promptly identify non-functional instruments and surface changes like pitting corrosion, and subsequently dispatch the corroded ones for repair, is needed to prevent a “worst-case scenario” of systematic corrosion. By ensuring that your team is aware of these things, you can help preserve the value of instruments, increase their life time and reduce costs for new purchases. [15]

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[1] Wong J, Khu KJ, Kaderali Z, et al. Delays in the operating room: signs of an imperfect system. Can J Surg 2010;53(3):189-95.
[2] Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg 2014;219(4):646-55.
[3] Childers CP, Maggard-Gibbons M. Understanding Costs of Care in the Operating Room. JAMA Surg 2018;153(4):e176233.
[4] Aesculap. Wrap to rigid. https://www.aesculapusa.com/en/healthcare-professionals/sterile-supply-management-solutions/sterile-container-systems/wrap-to-rigid.html
[5) Anderson D.J., et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008;29:51.
[6] Wick E.C., Shore A.D., Hirose K., et al. Readmission rates and cost following colorectal surgery. Dis Colon Rectum 2011;54(12):1475-79.
[7] Dancer SJ, Stewart M, Coulombe C, et al. Surgical site infections linked to contaminated surgical instruments. J Hosp Infect 2012;81(4):231-38.
[8] ECRI. Bioburden on Surgical Instruments: Patient Safety Advisory. Pennsylvania Patient Safety Reporting Sytem 2006(3).
[9] Lissovoy G de, Fraeman K, Hutchins V, et al. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 2009;37(5):387-97.
[10] Aesculap. Data on file.
[11] Yoon S, Zygourakis CC, Seaman J, et al. Implementation and Impact of a Hospital-Wide Instrument Set Review: Early Experiences at a Multisite Tertiary Care Academic Institution. Am J Med Qual 2019;34(1):67-73.
[12] Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg 2014;219(4):646-55. 
[13] Aesculap. Sterilization Validation – STERILCONTAINER with Primeline Lids. 
[14] Practice Greenhealth. Greening the OR: Reusable Hard Cases for Surgical Instrumentation 2013.
[15] Amann B, Appel T, Bertram M, et al. Corrosion: an underestimated risk. Zentralsterilisation 2019(5):320-23.