It might sound counterintuitive: How can an instrument that costs you several hundred pounds save you money compared to lower quality instruments that you can buy for a fraction of the price?
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Below are four clear reasons why:
1. Longevity
High quality surgical instruments are always manufactured with longevity in mind. Crafted by experts in instrument design and metallurgy, they understand how to create surgical tools that optimise performance and durability.
For example, top manufacturers will always choose the highest quality stainless steel rather than lower grade metal, as this will significantly enhance instrument longevity.
They are also likely to produce ceramic-coated instruments, which provide four to five times higher surface hardness than stainless steel, reduced abrasiveness and greater resistance to rust and corrosion.
They might also make instruments in Titanium, which is another high-performance metal that is recognised for its superior durability, being both fracture-proof and non-rusting.
What's more, instruments that are hand-crafted, rather than made by machine, can have incredibly long life expectancy.
For example, in a study to test whether Stille hand-crafted surgical scissors really did deliver on the manufacturer warranty of 30 years, it was found that 74% of the Stille scissors used in a busy surgical centre were actually older than 50 years.(1)
2. Cost-in-Use
Of course, whilst top surgeons and the sterilization services team might well value long-lasting surgical instruments, procurement teams charged with reducing operating room costs might find it hard to justify larger upfront costs for buying these products.
This is where a lifetime warranty comparison can really shine a light on the value of investing in higher quality instruments. By simply comparing the length of instrument warranties and dividing those time periods either by instrument cost or instrument use, it can be easily seen that the highest quality instruments will always be the star performers when it comes to value for money.
Obviously, high quality instruments with the longest warranties will prove the most cost-effective, so whichever instrument you are looking to purchase, make sure to research the various manufacturer warranties before buying anything. Whilst some will offer a 30-year warranty, others may only offer 1-5 years.
Alternatively, if your procurement team is considering single-use disposable instruments, a cost-in-use comparison with a high quality reusable instrument will invariably show the latter to be the most cost-effective investment.
For example, one study of laparoscopic instruments showed that 'the total cost for single-use instruments would have been more than seven times that for reusable instruments.'(2)
3. Minimal servicing costs
Another cost advantage to purchasing high quality surgical instruments is that they will often only need servicing every couple of years and some brands even offer the first service free within the initial purchase price.
What's more, some high-quality instruments will be designed to allow for the instrument parts to be dismantled during servicing by the manufacturer, allowing for thorough inspection of corrosion at the joints to help maximise instrument longevity.
Low-quality instruments will not only require servicing more regularly, causing greater cost and disruption to instrument availability, they are also more likely to develop hairline fractures and corroded surfaces that mean effective servicing is no longer possible.
4. Less environmental cost
There is also an environmental cost benefit for choosing long-lasting quality instruments over cheaper reusables in many cases.
For example, a study that compared mainly German brand reusable scissors to both German and Pakistani disposable scissors revealed that the reusable scissors were better for the environment. (3)
This is because whilst they take more energy to come to market, the reusable scissors are used thousands of times more than the disposable ones.
In addition, there is less ongoing environmental impact from servicing high-quality reusable surgical instruments than low-quality ones, which will require much more documentation, packaging, labelling and transportation for servicing.
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Hold out for high quality
As can be seen from the above, it is easy to justify the greater outlay for purchasing high-quality reusable surgical instruments, even in the face of significant budgetary pressures.
In fact, the rapidity with which poor quality instruments degrade means that, even if you have missed the boat for submitting instrument requests for this financial year, it is worth waiting until you have the budget to buy the best in twelve months' time.
To view our range of high-quality surgical instruments.
You can also contact our Cairn instrument team on 226 to arrange for a demonstration of our surgical instruments or to evaluate instruments on loan.
REFERENCES:
(1) Dahl G, Ölveback T, Wiklung L. Quality surgical instruments best investment. Presented: SEORNA, Swedish Operating Nurse Association Conference Meeting, 29-30 November
(2) Gabriel N Schaer, MD, Ossi R Koechli, MD and Urs Haller, MD. Single-use versus reusable laparoscopic surgical instruments: A comparative cost analysis. American Journal of Obstetrics & Gynecology Volume 173, Issue 6, Pages -, December
(3) http://www.sustainable-manufacturing.com/files/ 982_JGARG-Review_1-_Scissors_Aug_7g0i26.pdf
This study demonstrates the value of local quality control for surgical instruments. This is of importance in an increasingly hazard-conscious environment, where there are concerns over instrument sterilisation, surgical glove puncture and the potential for transmission of blood-borne and prion diseases.
Of instruments examined, 15% had potential problems. These included 116 with machining burrs and debris in the teeth of the tissue-holding regions, 71 defects of ratcheted instruments, 34 scissors with deficient cutting action, and 35 tissue forceps protruding guide pins. In addition, 254 instruments did not have a visible manufacturer's mark.
Between January and June , all batches of new surgical instruments ordered by the Central Sterile Supplies Department of St Bartholomew's and the Royal London Hospitals were assessed by three clinical engineers, with reference to British Standards (BS) requirements.
Many surgeons will have encountered the scissors that would not cut, and the artery clip that comes off in a deep difficult location, but it would be reasonable to assume that new instruments should be of assured quality. This study reports the surprising findings of a local quality control exercise for new instruments supplied to a single trust.
A surgeon performing a surgical procedure should be able to assume that the instruments used are safe and reliable ' particularly if they are new. To ensure the quality of these instruments, the Health Care Standards Policy Committee directed the British Standards Institution to produce requirements for the materials, design, dimensions and other features of surgical instruments. As a result, British Standards (BS), incorporating International Organisation of Standardisation (ISO) standards, were published.1 Each year, large numbers of new instruments are ordered by healthcare facilities across the UK, and those ordering them should be able to rely on these standards. This study reports the results of local quality control by the clinical engineering department of all new instruments supplied to a single NHS trust.
Over a 6-month period between January and June , all new batches of surgical instruments delivered to the Barts and the London NHS Trust, from a variety of manufacturers, were assessed by three clinical engineers. The suppliers and manufacturers were informed beforehand. Where large numbers of identical instruments were delivered in a single batch, samples of these were examined as follows: 25'49 instruments 50%, 50'74 instruments 30%, 75'99 instruments 20%, and 100+ instruments 15%. In total, instruments were inspected, where necessary under magnification, for flaws as defined under BS quality assurance requirements.
Magnified views showing a crack though the screw-head of fine scissors on the left, a cracked needle holder tip in the middle, and absence of solder to secure the jaw surface insert of a wire holder on the right.
In total, 730 (15%) instruments failed the inspection. Table 1 shows the flaws that were identified. Figure 1 shows 3 views of the jaws of vascular clamps: a well-finished instrument on the left, an instrument with machining burrs in the teeth in the middle view and right views. Figure 2 shows a crack in the securing screw of scissors on the left, a crack though the end of the jaws of a needle holder in the middle view, and a major soldering fault in the surface of a wire bending forcep on the right. Figure 3 demonstrates protrusion of a sharp guide pin on gentle closure of tissue forceps.
The commonest fault identified was lack of a maker's mark. BS states that 'the instrument shall be marked with the name or registered trade mark of the manufacturer or supplier'.1 This may seem like a minor infringement, but in fact it is highly important. If an instrument fails in service, it is essential that the supplier and manufacturer can be notified, so that any potential problem can be rectified, to ensure the safety of the patient and theatre staff. In addition, there is the question of liability and insurance.
The commonest mechanical and structural fault was machining burr debris. BS states that 'all surfaces must be free from pores, crevices and grinding marks'.1 The fine metallic surfaces of surgical instruments are the product of a number of engineering processes. The shapes and details are initially created by casting and pressing the metal into the required shape, but then finer detail is ground in. In modern, computer-controlled, laser-guided engineering, this should be a straightforward and reliable process, producing an extremely accurate surface, as is shown in the upper view of Figure 1. Sometimes, older methods are used but a fine finish should still be possible, as long as the surface is inspected and machine brush-polished. If this process is incomplete, metallic debris and surface imperfections will remain as shown in the middle view of Figure 1. This may be a problem in a number of ways. First, blood and tissue debris may collect in the imperfect surface. We have traditionally relied on sterilisation procedures to render such debris inert, but there are now concerns that prion disease may survive such processes.2 The metallic fragments may also wear off these surfaces, and remain as microscopic debris in the wound. Sharp burrs on instrument handles may contribute to previously unexplained surgical glove punctures. Although we cannot reference any reported instance of this, BS states that 'there shall be no sharp edges other than those required by the pattern of the instrument'.1
Cracks and soldering faults may also provide niches for retention of blood and tissue, and serious defects may lead to instrument failure, such as the examples shown in Figure 2.
Every surgeon must have encountered the scissors that do not cut but, surprisingly, this can be a problem with new scissors. In this study, 34 scissors of various types did not meet the simple BS requirement, which describes how wet tissue paper (for fine dissecting scissors) and no. 18 gauze (for heavy tissue and suture scissors) must be cut cleanly and without tearing, for two-thirds of the length of the cutting blades.1
Most surgeons will also know the problem of the artery clip which comes off in a deep, difficult location. Contrary to popular myth, most surgeons do criticise their own technique for such problems, but may now be surprised to find that we identified 71 ratchet problems in new artery clips. BS describes in detail how the racks of these instruments should function so that they 'mate accurately when engaged',1 and should not spring open when left closed for 3 h on a test wire of specified diameter. The instruments that failed our assessments all had racks that did not engage correctly, and sprang open when tested in this way.
Many fine tissue forceps have guide pins to re-inforce the accuracy of the jaws mating. BS states that 'if present, the guide pin shall be tapered to facilitate entry into the locating hole and shall not protrude from the hole when the jaws are closed'.1 We identified 35 guide pins which protruded on light, but complete, closure of the forceps' jaws on naked eye inspection. This may be a source of glove puncture.
The stainless steel alloy from which modern instruments are made must also conform to BS. Procedures are described to test corrosion resistance, but it surprised us to find visible corrosion on new instruments.
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