Reduce, Reuse, Rethink: Cost of Ownership and Sustainability

Procurement decisions are usually driven by cost and performance. This is true regardless of industry; hospitals and medical facilities are no exception. If the only performance measure that matters is how many patients you can serve each day, then patient care will suffer. A holistic approach that focuses on patient experience and outcomes will improve your facility’s reputation, make it a better place to work, and provide a better return on investment (ROI).

The holistic approach extends to procurement when you choose truly reusable products, select consumables that are safer for patients and staff, and invest in training to ensure that staff understand best practices and the importance of proper care and handling to maintain your investment. Doing that might appear to cost more in the short term but can result in lower costs over the lifetime of a product. Total Cost Of Ownership (COO) considers the entire life cycle of the products you buy and how they are used. It includes not only upfront costs but also the longevity of durable supplies, how often consumables need to be purchased, the energy required to run equipment, and hazardous and nonhazardous waste disposal fees.

COO calculations look beyond immediate income and expenses in the present to consider long-term savings in the future. Sustainability considerations do as well. In many cases, the answer that reduces total COO is also better for human health and the environment. This article examines COO in the context of cleaning, sterilizing, and disinfecting in the sterile processing department (SPD) and how sound buying decisions contribute to better value.

Disposable Versus Reusable

Hospitals can fall into the trap of assuming that disposable packaging and single-use instruments are the best way to ensure patient safety and avoid cross-contamination. As a result, they continually buy disposables that get incinerated or landfilled. This practice is wasteful, costly, and unnecessary. Some disposable items, such as gloves and masks, are needed. Others, such as single-use packaging (peel packs, wrapped trays, etc.), can be replaced with metal trays packaged inside reusable sterilization containers to eliminate the need for blue wrap.

Reusable medical devices, when appropriately processed, save money and reduce waste. Proper care and handling of all reusable items is critical. All reusable devices must be cleaned and rinsed after each use. Healthcare personnel should follow the instructions for use (IFU) for all equipment and instruments and ask questions if there is anything they don’t understand or when presented with conflicting information from different sources. They should also review processing instructions and cautions for care and handling, including labeling instrument cleaners for compatibility with the intended use.

Follow the IFU with a Discerning Eye

Personnel need to read IFUs with a critical eye to ensure that the IFU doesn’t promote a process or a product (i.e., a chemical) that is incompatible with the application in question or one that costs significantly more when another product can do the same or better at a lower acquisition price. For example, some pre-cleaning solutions form a film that encapsulates soil on devices. Personnel may think that the items are wet and were pre-treated correctly, but this is not the case. Residue and soils may be encapsulated, thus making it harder to clean down the line. Further, removing the soil requires extensive manual cleaning and brushing to remove the film, which wastes time, detergent, and water. A free-rinsing pretreatment agent would have been a much better option, as it facilitates soil removal instead of encapsulating the soil.

Staff training on proper cleaning and disinfection processes is essential, especially for reusable devices. Shortcuts in the moment often lead to undesirable outcomes, some of which can endanger staff and patient safety and some of which increase costs. Access to IFUs is another concern if the IFU is printed and stored in a remote location where staff might never see it. Instead, some companies, including Case Medical, introduced a paperless system where personnel can scan a bar code on an instrument container or other reusable device and view the relevant IFUs in real time. This streamlines the process, increases productivity and patient safety, and eliminates paper, improving total COO.

How Instruments Can Last Longer

The total COO for reusable surgical instruments and trays depends on how long the products last. The first step is buying high-quality durable goods, and the second step is treating them properly so that they last longer. With proper care, reusable instruments can last much longer than manufacturers' estimates.

Some cleaning chemicals degrade metal surfaces, leading to premature disposal and replacement of devices that are otherwise perfectly functional.  Since the pandemic, there has been an increased use of germicidal cleaners, including environmental wipes, in sterile processing. Routine use of these alkaline or acidic chemicals for both cleaning and disinfecting contributes to poor performance and degradation, as surfaces and devices are rarely cleaned or rinsed beforehand. When germicidal cleaners come in the form of single-use wipes that are not biodegradable, this becomes another source of excess waste.

Alkaline cleaners are a contributor to rising costs. They don’t just dissolve bodily fluids or organic soils on contaminated tools and instruments. They dissolve the metal surface and cause pitting, destroying the protective coating and shortening the tool’s useful life. Thorough rinsing is essential to remove both biological contamination and detergent residue. That way, a cleaned instrument is safe to handle even before it is sterilized for reuse and subsequent patient care.

The Risks of Hazardous Chemicals

Many healthcare professionals believe that the stronger the chemical, the more effective it is for cleaning and disinfecting. To them, the smell of bleach might signify a clean, sterile environment. That approach ignores the safety concerns of handling or breathing highly caustic or acidic fumes and the risk of contaminating local wastewater streams with these products. Even some common household chemical products may cause immediate health effects, such as skin or eye irritation, burns, or even poisoning. Continued exposure to hazardous substances can cause cancer, skin disease, and respiratory illness.

Looking purely at the financial impact, hazardous waste and chemical disposal costs money. Organizations might be liable for the chemicals they release into waterways, incurring substantial fines and penalties. For example, California Proposition 65, Washington Senate Bill 5135, and the New York Clean Water Infrastructure Act specifically address these consequences.

As noted above, the damage to surgical devices from highly alkaline detergents is a substantial concern when considering COO because of the financial costs to repair or replace expensive devices and the reduced productivity that occurs when critical devices are not available when needed.

Safer Cleaning Chemicals and Ingredients

The U.S. Environmental Protection Agency’s Safer Choice Program is a resource for finding products and ingredients that have been validated to be the safest in their class. Enzymatic detergents fall into this category. Enzymes are catalysts, meaning they speed up reaction rates. All living things use enzymes that speed up reactions and help to digest food, and there are cleaners available with similar enzymes to break down soil and bioburden. Because of their catalytic action, enzymatic detergents can clean faster at lower temperatures. This advantage saves energy and improves COO.

Enzymatic detergents are typically pH neutral, like water, so they do not destroy medical devices or the passivation layers that protect medical devices from corrosion. These detergents effectively dissolve organic soil while being safe enough to pour down the drain. Various commercial formulations are available with different concentrations of one or more enzymes depending on the type of soil that needs to be removed and the cleaning process.

Cost Per Gallon Versus Cost Per Use

More is not necessarily needed or advantageous. When considering the cost of consumables like detergents, it is best to examine the per-use cost, as it affects a facility’s total inventory management. Cost per bottle, gallon, or liter is not the correct measurement because suggested dilution rates vary. Procurement should calculate consumption based on the actual expected use, which may differ depending on whether you use manual or automated cleaning or select detergent A or B. Further, review the suggested dilution rates found in the labeling. Some detergents have a validated narrow dilution range to ensure that only the correct amount of solution is drawn, a clear cost savings advantage over those with a large range, where the higher end of the range can be excessive, causing facilities to go through detergent faster than needed and run up expenses.

Highly concentrated detergents offer multiple benefits. They come in smaller bottles instead of huge drums that take up space that could be better used for other medical supplies or equipment or patient management. Compact bottles are much easier to handle, reducing storage space and ergonomic risk. The added advantage is not paying to ship gallons of water when water is readily available on-site to dilute the detergents, which is also a win for sustainability and COO. The total COO calculations for a specific consumable are only valid when the products are used as directed. The benefits of concentrated chemicals are best leveraged with safer options, such as enzymatic detergents, and when the label specifies a narrow dilution range to minimize consumption and waste.

Thoughtful Purchasing Results in Cost Savings

Healthcare facilities that purchase truly reusable equipment and protect that investment with sustainable, safer chemicals for cleaning and processing, followed by sterilization, will see multiple benefits. Facilities will save money when they make value-based purchasing decisions. Unnecessary repair and replacement of equipment can be avoided when best practices for cleaning and rinsing are followed, using safer detergents.

Total cost of ownership benefits will best be realized by looking holistically at an entire system or process rather than focusing on whether you are going to buy product A or product B solely on price alone. Another thoughtful strategy is to review your entire inventory of devices and consumables to determine whether all the products you buy are truly needed. Standardization helps reduce total COO. Trays with modular components and flexible configurations, as well as containers with universal compatibility, maintained with a line of safer concentrated cleaning chemicals with validated narrow dilution options, allow facilities to reduce stock levels and lower inventory management costs. Standardizing a facility’s instrument chemistries avoids concerns about how different chemicals will interact with each other or affect the functionality and use life of critical medical devices.

Focusing on value-based procurement decisions allows healthcare facilities to streamline their purchasing decisions and achieve a lower total cost of ownership while improving staff and patient safety. That winning combination benefits staff, patients, and the facility’s bottom line.

Frieze and Freer Goldstein were featured on a recent episode of Healthcare Purchasing News’ podcast, Healthcare Hodgepodge, discussing this same topic.