DISCUSSION

Sterile processing is an essential aspect of all healthcare systems; inpatient and surgical programs depend upon sterile instruments to safely provide advanced medical care.Reference Burlingame ^{2 –} Reference Chobin and Swanson ⁴ Over the course of several years, our facility experienced several episodes of SPS quality-assurance challenges resulting from steam quality and infrastructure concerns. These quality gaps led to several interruptions in clinical operations across many disciplines, including surgery, medical subspecialties, and dermatology, among others.Reference Hernandez ⁵

Sterile processing challenges are not unique to our facility.Reference Hernandez ^{5 ,} Reference Blackmore, Bishop, Luker and Williams ⁶ The New York University Hospital System was forced to identify SPS alternatives following catastrophic damage to facility infrastructure after Hurricane Sandy.Reference Adalja, Watson, Bouri, Minton, Morhard and Toner ^{7 ,} Reference Evans ⁸ In July, 2015, the largest hospital in Texas was forced to shut down surgical operations after SPS quality-assurance concerns similar to those experienced at our facility were identified. Most recently, Detroit Medical Center was found to have SPS quality assurance challenges and may face loss of Medicare and Medicaid funding after an unannounced inspection by the Centers for Medicare and Medicaid Services (CMS) in August 2016.Reference Punke ⁹ A repeat inspection will determine the termination or continuation of the contract between CMS and the medical center, with potentially dire economic consequences for the facility.Reference Punke ⁹

We found several key factors that affect the optimal economic strategy for supporting SPS. The following variables should be considered: (1) expected duration of the potential solution, (2) facility capacity for accommodating the solution in terms of logistics, (3) infrastructure (eg, the amount of reuseable medical equipment needed, based on changes in sterilization turnaround time and utilities and physical space to accommodate mobile sterilization units), and (4) any regulatory issues that may create barriers to different strategies.

Feasibility is an additional consideration. Repairing or replacing internal water and steam systems was not an option for our facility, but it may be an economically sound strategy for facilities with fewer infrastructure challenges. Our facility is in an urban setting; thus, outsourcing was an available option. However, rural healthcare systems lacking nearby facilities with necessary infrastructure to support increased SPS demand may not be able to implement this strategy.

Our analysis has several limitations. First, our data are based on a VA facility that has a different economic structure than private healthcare systems. Costs of implementation delays were not quantified or included in cost estimates; however, costs for strategies that can be implemented quickly would be minimally affected by loss of patients and clinical care staff and would also be less likely to be negatively impacted by other intangible costs, such as potential loss of training programs, loss of staff, or loss of Medicare and Medicaid reimbursements. Thus, strategies most significantly impacted by implementation delays (ie, lease or purchase of a sterilization trailer) are less attractive economically than outsourcing. Finally, our cost estimate of outsourcing sterile processing to another facility is based on the volume of our operating room and hospital; the relative costs may be different at different levels of surgical and sterile processing volume.

In conclusion, the most economically sound option for reopening sterilization operations varies depending on the root cause of the problem and its projected time horizon. Sterile process service shutdowns are associated with substantial downstream negative effects that should be considered when evaluating potential solutions.