I’m Todd Schlosser and today my guest is Gregg Agoston, the VP of Surgical Services at Specialty Care. I feel very lucky to have caught up with Gregg at a convention recently so that we could discuss the silent epidemic that is currently taking place at hospitals across America. What exactly is causing those issues and what can be done to resolve them? I think you’ll also be very interested to hear what he has to say about the rate of surgical site infections and how a sterile processing department, when utilized correctly, can really mitigate those issues. Enjoy the conversation.
Todd Schlosser: Hello and welcome to Checking the Vitals, a podcast powered by Specialty Care. I’m Todd Schlosser and today my guest is Gregg Agoston, the VP of Surgical Services at Specialty Care. I feel very lucky to have caught up with Gregg at a convention recently so that we could discuss the silent epidemic that is currently taking place at hospitals across America. What exactly is causing those issues and what can be done to resolve them? I think you’ll also be very interested to hear what he has to say about the rate of surgical site infections and how a sterile processing department, when utilized correctly, can really mitigate those issues. Enjoy the conversation. I’d like to start off the conversations by asking people what drew them to want to work in a career in healthcare. Do you have a story or a reason that made you passionate to work in this space?
Gregg Agoston: Yeah. When I graduated from college and was looking at careers, I had a degree in marketing and wanted to get into something that I felt passionate about and I went on interviews and I talked to a guy that sold meat, like deli meats and I talked to a company that sold elevators and escalators and while they were good, well known companies, there wasn’t any spark. I started looking and I found a position with a pharmaceutical company. I thought this was great because I could do something in healthcare and I could help people and so I started my career in pharmaceuticals and I spent 13 years at that and then decided that I wanted to move over to medical equipment and then moved to actual durable equipment after that.
Todd Schlosser: And that’s sort of what got you into the sterile processing space, I’d imagine?
Gregg Agoston: Yeah. The first position I had was starting out, actually my older brother who worked for American Hospital Supply as a B Miller salesperson. He had started some other businesses and one of the businesses was one that we were doing outsourcing of minimally invasive instruments, supplying technicians. This was very early on. We were one of the genesis of supplying outside support for hospitals and sterile processing. At the time, endoscopic or laparoscopic procedures, Lap Chole was really just at the boom and there was a great need for equipment. There was a great need for technical expertise to manage this new video equipment, the cameras, the scope [inaudible 00:02:33], instruments and so there was a need at that point where they needed because of the dangers of having equipment that didn’t work properly, having an outside source come in that had expertise with the equipment to help and manage that equipment.
Gregg Agoston: We would do all the functional testing, the repair, the replacement on the equipment, making sure that it was and 100% for each and every patient. There’s real value to the patients in that and I think that through that business we started and it was very successful. Eventually Carbon Health bought us. I stayed with them for a couple of years and then moved over to another major endoscopy company. I worked with them for 13 years and created programs with them related to SPD and the common thread through this was that all along I was working in sterile processing departments across the country and I saw how much many of the departments struggling. Not all of them, there’s some that are just things are working very well but there is a large number of them that have many challenges related to just maintaining the proper staffing with the technical expertise in that managed equipment.
Todd Schlosser: If you don’t mind, can we get into some of what some of those challenges are and those kinds of things. If you walked into just a regular, not the best, not the worst, what are some very common problems a sterile processing unit might face?
Gregg Agoston: Yeah. There’s common threads and common themes. Number one is kind of employee morale and employee turnover. That’s really related to the pay that the people receive. Very often. I mean it’s sad to say. I mean and maybe historically, I’ll back up, because I think the historical significance of how sterile processing was formed initially is important. Prior to the central sterile processing department being formed, it used to be that most of the operating rooms had their own processing area. The floors in the hospital had their own processing area to do instrumentations. They were cleaning and sterilizing in the operating room up on the floors and the different departments that use instrumentation. From a standardization perspective, it was much better to consolidate that and they did that by the creation of the sterile processing. They wanted to have standards, they wanted to make sure that everything was processed consistently because it’s very difficult to manage when it’s all scattered throughout the hospital and all these clinics potentially-
Todd Schlosser: Yeah. Because it’s so spread out. You want to have a unified center that handles it, I’d imagine.
Gregg Agoston: … Plus from a production standpoint rather than having all of this equipment scattered around and different people doing the different functions taking it out of the operating room, one did a couple things that remove the potential contamination in the operating room area so that removed that from the patient area, which was good. It also took the responsibility for cleaning instruments away from the nursing staff so now the nursing staff could be much more focused on the patients versus the instruments but what was missed in that, because I think at some points it was seeing that by doing that instrumentation is more of like spoons and forks and way back when 30, 40 years ago we didn’t have all the complex instrumentation that we have today. It was a lot of general stainless steel instrumentation and equipment so it wasn’t what I would consider complex equipment.
Todd Schlosser: Right. And now they are very complex. I mean it isn’t spoons and forks and dishes, like it’s very complex instruments that you have to get in and really minutely clean them or you’re going to have a lot of issues
Gregg Agoston: And understanding the equipment is extremely important. The challenge is, is that they took all of the equipment, they brought it into the central sterile department. They brought in staff to clean and to sterilize the equipment but now you went from a situation where before the nurses were experts with the instruments because they were actually in the room when the surgeon was using the equipment, they knew the instrumentation. They knew it by name, they knew what it was used for, they knew why it was used, how it was used. They knew what happened when it would fail. They were expert with the instrumentation.
Gregg Agoston: Now you consolidate that into a department and now you challenge this department with cleaning every single piece of instrumentation in the hospital. It could be everything from the scopes they use up in the ICU to instruments in the ICU to scopes from a GI center or scopes that are using it in the operating room as well as all the power tools and all of the other sophisticated instrumentation.
Todd Schlosser: Yeah. Da Vinci machines and yeah, that are … cleaning those are huge processes. It’s not like a 10 minute thing.
Gregg Agoston: And 40 years ago we didn’t have all that complex equipment. Okay. Initially it kind of started out where it made good sense but the two primary faults I think are, one is administration really not recognizing the importance of sterile processing overall and the complexity of the equipment as it evolved. That’s a big challenge. As we did develop into endoscopic procedures and the cameras and the scopes and now you’re talking things that, a scissor may cost 20 or $30 for a scissor. Some scissors are more but there’s scissors that may be 6 or $7 too. You go from a piece of equipment like that to origin endoscope that is going to cost, the hospital is going to pay probably 3,500 to $5,000 for these rigid endoscopes.
Todd Schlosser: Yeah. You can’t just throw them away at the end of every surgery. Yeah.
Gregg Agoston: Yeah. That’s one scope but camera is 12,000 to $14,000. You get a flexible endoscope and you’re talking 25 to 35 there’s some flex of endoscopes that have very sophisticated microscopes and ultrasound units in them that are over $100,000 a piece.
Todd Schlosser: Wow. Okay. I had no idea that that was the case.
Gregg Agoston: We took all of that equipment, put it in this centralized department and unfortunately the staff there has been kind of treated like the cleaning department, like they’re cleaning spoons and forks and-
Todd Schlosser: I mean I’ve heard someone say that they are looked at as sort of like the dishwashers of the hospital, which if you spend three minutes in one of those departments, which I was fortunate enough to do and we were able to walk through one, I was blown away by the specialization they have to know for every instrument. It’s not like you’re putting dishes in a rack and throwing it through a cleaner. It’s not like that at all.
Gregg Agoston: … No. The staff and the sterile processing has got to know what the instrument is. They’ve got to know how to disassemble it. If it needs to be disassembled, they got to know what steps to go through to properly clean it and then on the other side they’ve got to know how to prepare it and inspect it to see if it works properly, package it properly and then sterilize it. Now again, with everything coming into … in a large hospital where you’ve got 10, 15, 20, 40 ORs, you’ve got all types of surgical specialties and the surgeons and the nurses typically are able to specialize to some degree meaning that orthopedic nurses tend to do orthopedic cases. The nurses that do the eye procedures typically do the eye procedures but now we took all of that sophisticated equipment and we’ve put it into one department and we expect the people that come in either from a community college with certification or training and sterile processing.
Gregg Agoston: Oftentimes people hire the employees off the street and train them internally or they hire them from other hospitals typically or maybe they promote up from within maybe coming from food services within the hospital but move over to sterile processing. The fact of the matter is many of these people starting pay on average is probably around $11. 11 to $13 an hour to start and they’re expected to know every single piece of equipment in the hospital. The other challenges is that because of the way sterile processing set up, there’s really not a specialization in sterile processing in most hospitals. Now again, I’m speaking in general because some hospitals do have it and many jobs-
Todd Schlosser: In any industry, you’re going to have the people who do it well and the people who don’t do it well and a lot of people are in between that.
Gregg Agoston: Exactly. One of the roles in the sterile processing department is oftentimes the people just rotate through the different areas. You can have a very tenured person who may be very well trained and knows the equipment because they’ve been there for 15, 20 years and today they’re doing the decontamination and tomorrow they’re doing prep and pack and the next day they’re doing pulling the case cards or pulling the materials to send upstairs to the OR. The next day they’re open, the GI center, maybe if they’ve got some places that sterile processing also process the GI scopes. They’re exposed to every single instrument in the hospital and then if they’re doing prep and pack, anything that’s sitting there that needs to be packaged, they have to package, whether it’s an [eye 00:00:11:26], set, an orthopedic set, it’s a laparoscopic set, you name it-
Todd Schlosser: Anything going on in the hospital really.
Gregg Agoston: … Any instrument in the hospital and when you consider that a hospital may have 1500 different instruments sets-
Todd Schlosser: I didn’t realize it was that many.
Gregg Agoston: … There’s really tens of thousands of instruments in a hospital and we’ve been in hospitals where in the morning come in and there’s 3 to 400 instruments sets just sitting on the shelves waiting to be assembled and now it’s like, okay, what do I pull? They’re going to go pull a tray and they’re going to try to assemble it and they’re going off a little menu. Sometimes the menus have pictures, sometimes they don’t.
Todd Schlosser: I would imagine they would need to. If you’re looking at 15 … these are 15,000 different types of instruments.
Gregg Agoston: I mean there’s thousands of instruments.
Todd Schlosser: You could work for hours or hours a day, every day for three years and not have seen every one of them. That’s insane.
Gregg Agoston: Yeah. Well, the fact is is that they will see every one of them because they have to see every one of them. The question is do they recognize it?
Todd Schlosser: Or will they remember it?
Gregg Agoston: Do they know what it is, what it’s used for, how it’s to be assembled-
Todd Schlosser: And probably how to clean it.
Gregg Agoston: … Well, I mean there’s separate things. If you’re working in decontamination, you’ve got to know all that about like what do I do to this not to hurt it and we see mistakes made, we see common mistakes because people will generally try to do what they think is not going to hurt the equipment. You kind of get the average of what supposed to be done. Like I know I can rinse it off but I don’t know if I can S submerge it into water to clean it. Maybe I’ll keep it out of the water and just kind of wash it as best I can and kind of gently rinse it because I don’t know if I can submerge it to wash it but the reality is it’s something like that, if it’s being hand washed only then it may not be properly washed and we see examples of that where instrumentation that’s hand washed only comes through and it still has bioburden on it, on the ‘clean side’ of sterile processing.
Todd Schlosser: Before you use bioburden again, because this is something that was new to me and I had no idea what it was until maybe our third conversation. Could you go into a little bit of detail that bioburden actually is?
Gregg Agoston: Bioburden is in essence remanence of the patient that it was just used, that instrument was just used on. It’s blood, it’s tissue, it’s body fluids, it’s whatever mucus, whatever was exposed to that instrument that remains behind. The reality is that that material can contain bacteria or bacteria can grow on that material if there’s moisture available and it creates a problem and so soil that’s left on an instrument, if it gets mixed with bacteria, bacteria will set up shop on that location and these things called bio films now that are so much in the news is that the bacteria we found are actually much more sophisticated than where we thought.
Gregg Agoston: When you went through high school biology and you looked through a microscope and you saw your first bacteria, some little planktonic material growing or moving around in the Petri dish or on the lens, we now know that those organisms, bacteria can communicate and they send signals out and they basically colonize an area if there’s food and if there’s moisture, they’ll try to colonize and they grow very rapidly and once they start to colonize, they also form a shield over themselves. They put this little covering over top of them called a biofilm and they live inside that little colony and they communicate and they worked symbiotically to perpetuate that colony, whether it’s protection or growth and distribution of more bacteria.
Todd Schlosser: When they’re living in this colony, having their hay day, if they don’t get properly washed off or cleaned or the instrument that they’re living on doesn’t get sanitized correctly because of all these problems that you’ve sort of laid out, what are the repercussions of that?
Gregg Agoston: Yeah. Infection is the primary repercussion. The key is with instrumentation an I use this example a lot. If you have a fried egg, you’ve got your plate and your fried egg and you get some yolk that’s spills out of the egg and lays on the plate, you know that if you go to wash that, the longer that sits there, that protein material sits there, the harder it is to remove from that-
Todd Schlosser: It can become concrete.
Gregg Agoston: … Can become concrete. That’s the same thing with a biofilm. Biofilm basically becomes like concrete. It’s immense itself to the instrument protects itself from chemicals by the shield that it builds over itself and it becomes very hard to remove. The longer the instruments sit after years before they actually get processed to be cleaned, the worst that is and now we’ve got these again, a scissor is one thing where you can kind of you’ve got a hinge area but it’s relatively a general instrument. Pretty straight forward.
Gregg Agoston: When you get to a flexible endoscope that have these long lumens, these channels that can be four or five feet long, you’ve got a brush there, you can’t see inside of it. You really don’t know if you’re removing everything. It becomes problematic and unfortunately we hear and we know cases that instrumentation has not been properly cleaned. Shows up in the operating room and patients are exposed to this material. Being exposed to it definitely increases the risk of surgical site infections and that’s what all of us need to prevent because surgical site infections, we know that there’s kind of a perfect storm brewing for our population.
Gregg Agoston: One, is that we’ve got more elderly people going to demand more surgery. Okay. Two, is we know that the bacteria is much more [inaudible 00:16:52], now than it once was because it’s been exposed to chemicals and antibiotics so it’s harder to kill and we know that resistance of bacteria is increasing. We’re now, it’s not years like when penicillin first came out, it was many years before the first resistance. Now, they’re literally measuring resistance in weeks and days and shorter periods because the bacteria has become that much more difficult to kill.
Todd Schlosser: And resilient. Yeah.
Gregg Agoston: And resilient. Yeah. And the other thing is is we don’t have that many new antibiotics coming out. It becomes extremely important that everybody does everything they can to prevent any type of exposure to material that should not be on an instrument. Technically of an instrument is not clean. It cannot be considered sterile and so that’s the genesis of you’ve got to have people who are really knowledgeable and understand the equipment and properly clean it without doing damage to the instrument but yet thoroughly cleaning it to remove all that soil or bioburden.
Todd Schlosser: And I realized this is like a world you live in and have lived in for quite some time and you’re sort of an expert at it but how big is the problem? Is it something that not many hospitals deal with, every hospital deals with, some hospitals deal with? How big is it?
Gregg Agoston: Yeah. I mean the reality is that probably on a daily basis in hospitals all across the country, there’s instrumentation going into operating rooms that have not been properly cleaned or processed. I think it’s-
Todd Schlosser: Everyday in every hospital that’s happening?
Gregg Agoston: If it’s not every day, it’s probably every week. It’s a silent epidemic. I really believe it’s a silent epidemic from what I’ve seen. When you talk to the nursing staff and you talked to the people whether or not they see it or not. Now whether … the nurse may not recognize that there’s bioburden on instruments coming into the room-
Todd Schlosser: Sure. Because there are some plays on those scopes. You can’t see that.
Gregg Agoston: You can’t see. You don’t know. You’re trusting and what happens is there’s a trust and fortunately antibiotics and proper procedures because there’s multiple procedures that are done to prevent infection from surgical site infections but we know that everything else that has surgical site infections over the last really 10 years as I’ve been tracking really have not decreased. For the types of procedures that we’re tracking-
Todd Schlosser: We’ve only been tracking them for 10 years?
Gregg Agoston: … Well I think … I mean it’s gone back to like 1992 I think was when they first started tracking-
Todd Schlosser: So it’s relatively recent.
Gregg Agoston: … couple of different procedure types but it’s relatively stayed the same. They’re reporting a 73,000 surgical site infections but that’s related only to two surgical procedures. Colon procedures and vaginal hysterectomy.
Todd Schlosser: For two different procedures, there were 73,000 is that since ’92?
Gregg Agoston: That’s where they’re tracking and recording the information. No, per year.
Todd Schlosser: Whoa. Per year.
Gregg Agoston: Yeah.
Todd Schlosser: So 72,000 per year for just two types of surgery.
Gregg Agoston: Yeah. Two types of surgeries. Yeah. I do a lot of presentations and presentations I’ve been in, one of my first questions is how many of you in this grew either know of someone, either close friend, relative, acquaintance that has had a surgical site infection and it’s amazing how many hands will go up. I mean literally at conferences where these people work in sterile processing, half the hands will go up in the room that they know someone.
Gregg Agoston: I know personally, a friend of mine was telling me and his wife works in the operating room at the hospital he had a surgical procedures. He went in for two different procedures, one shoulder, one knee and both of them developed infections postdoc. Now can we say, is that due to a dirty instrument or was it due to maybe antibiotics not being given at the right time or the prep for him or he was just the unlucky patient? There’s multiple factors that go into determining whether or not a patient will have a surgical site infection.
Gregg Agoston: Specifically when it comes back to sterile processing and their role there’s, two primary areas that they impact those factors. The first factor is the longer a patient is exposed to the operating room environment, the greater the risk of surgical site infection. Okay. The longer you’re in that room, the greater your chances are you’re going to get an infection post op and that’s the first one.
Gregg Agoston: How does sterile processing impact that? One, they impact that by if instrumentation shows up in the room and they open up the instruments and they find that there’s something that’s missing, broken or not working, functioning properly-
Todd Schlosser: They’ve got to get another set up.
Gregg Agoston: … they’ve got to wait and it delays and an extends the patient’s exposure time. The second area is dirty or non sterile equipment. That’s the second function. If an instrument comes up and it still has bioburden or debris that’s on the instrument or in the container or foreign materials in the container or if the item wasn’t properly processed, then there’s a greater risk that that equipment is not sterile.
Gregg Agoston: It’s always got to be cleaned to be sterile but the assumption is when it shows up, it’s sterile and I’ve literally had surgeons come up to me and ask me, one in particular I’ll never forget, he said, “I’m in doing a knee arthroscopy and I’m seeing a little black flakes inside the joint space, can you tell me what that is?” And unfortunately what that is is the instruments that they’re using, there’s blood that’s-
Todd Schlosser: From previous surgery.
Gregg Agoston: … from previous surgery is basically flaking out.
Todd Schlosser: That would be that bioburden.
Gregg Agoston: Exactly.
Todd Schlosser: Oh man.
Gregg Agoston: Exactly. Yeah. S.
Todd Schlosser: That’s literally the last patient is on your new patient’s knee.
Gregg Agoston: Exactly. Or as many patients that were inside that instrument. Yeah.
Todd Schlosser: Yeah. Man. It seems like this problem, if you want to call it, that silent epidemic, if you will, it’s multifaceted and it doesn’t seem like there is a silver bullet to fixing it but what sort of steps could you take if you were like a hospital manager or OR manager, how could you help isolate this problem and solve it?
Gregg Agoston: Yeah. I’m very passionate about, one thing is, is that getting sterile processing the recognition for the work that they do and the importance of the work. I mean, I have different analogies of what sterile processing is. To me, sterile processing is the heart of the operating room because what they pump out, the materials, the instruments and disposable supplies that they sent up to the operating room is the blood. The operating room may be the brains, they do the procedures but they can’t do their work, the brain dies if it doesn’t have blood. Okay. If the equipment doesn’t come up, if it’s properly prepared that it’s on time, it’s available and it’s functional. If it doesn’t meet those three criteria then the operating room suffers and ultimately the patient suffers.
Todd Schlosser: It’s almost like safer surgery doesn’t start in the surgical OR, it starts in the SPD or the …
Gregg Agoston: Absolutely. Because that really is the origin of the instrumentation-
Todd Schlosser: Because if you get bad instruments, you’re going to get bad outcomes.
Gregg Agoston: Exactly. Eventually you’re going to end up with bad outcomes.
Todd Schlosser: Yeah.
Gregg Agoston: Yeah.
Todd Schlosser: What else can be done to sort of resolve that?
Gregg Agoston: The resolution for this in my opinion, is first that the recognition by the leadership of the hospitals of the importance of sterile process. We can’t bring people into these departments, [inaudible 00:24:02], minimum wage or close to that. I mean, I was at the hospitals, in Texas they were saying they’re starting people out a little less than $10 an hour.
Todd Schlosser: [inaudible 00:24:12], at Chick-fil-A for that.
Gregg Agoston: And that’s the problem because people come in, they’ll come in, they’ll leave to go to work for the department store, any place that pays more and unfortunately, sterile processing is not a glamorous position. I mean, we’re dealing with contaminated bloody instruments, potentially instruments that carry hepatitis, AIDS virus. There’s danger associated with working with this equipment. You’re working in a department typically that’s doesn’t have windows. You’re lifting heavy items, you’re having to stand over a sink and clean wash these things all day long and as your turn and rotate through that area.
Gregg Agoston: It’s not glamorous and oftentimes the people in the operating room then get the … communication from the operating room is not all that positive because they only hear when things are not right and I’ve literally been in offices of the sterile processing manager when the nurse comes down or a physician comes down and it is not a pleasant scene because something wasn’t set up right but yet we’re tasking the people in sterile processing with an almost, it’s like they really can’t succeed based upon the parameters that have been set up for sterile processing because sterile processing has not evolved like the operating room. The operating room has been allowed to specialize more so than sterile processing and then when I say that in meetings with people, people will say, “Well, we can’t specialize. I can’t have like one person down in sterile processing who only cleans because nobody wants to do that.” Or, “I can’t have one person who only does the orthopedic sets because we got so many sets coming through and we don’t do that many cases a day. That person will be staying in there for half a day.”
Gregg Agoston: I understand that but there is a way that you can designate instrumentation between general instrumentation and complex instruments.
Todd Schlosser: Sort of specialized instrumentation. Yeah.
Gregg Agoston: Exactly. Complex instruments are those devices that would be related to like power tools, endoscopes, flexible and rigid semi-rigid, minimally invasive instruments and in any key areas in the hospital that the hospital says this is like we do a lot of work in this area. Orthopedics maybe. We need a specialist for orthopedics because we’ve got such high volume just to make sure that those sets are always put together. Plus and when you deal in orthopedics there’s a lot of loaner sets that come in and so really manufacturers will bring an instrument set or multiple instruments sets, I mean 10, 15 sets in for one surgical procedure for a patient and drop it off the night before and expect the sterile processing department to know all of the instrumentation in this equipment that’s not even there as it’s on loan for that particular case. It is extremely challenging.
Todd Schlosser: Yeah. Sounds like it. How do we get the message out about this silent epidemic that’s going on? I was blown away by that 37,000 number that was … and I thought it was all the way from ’92 but it was actually from every year.
Gregg Agoston: It was 73,000 [inaudible 00:27:03].
Todd Schlosser: 73,000. Yeah. And it’s just those two types of surgeries. There’s so many types of surgeries that go on.
Gregg Agoston: Yeah.
Todd Schlosser: So that means it’s exponentially bigger than that.
Gregg Agoston: Yeah. It is exponentially bigger and the impact to healthcare is billions of dollars. I mean billions of dollars from when you consider the extra state. Typically, people that get a surgical site infection are in the hospital, 7 to 11 days longer. There’s all the lost work time, expense and the reality is is it’s a personal, it’s the impact on the person because when somebody has a surgical site infection, I mean, it is catastrophic. I mean it is life and death. They’ve got a much higher rate of death. If you get a surgical site infection, people get exposed to antibiotics for months, sometimes even longer to try to cure these problems so it takes real toll on the person, on their family, on their economics and finances.
Gregg Agoston: It is a major, major issue when that occurs and unfortunately it occurs too frequently. That’s the whole purpose of why we’ve got to do everything we can to prevent that from occurring. Again, we know that there’s multiple factors there that build to surgical site infections but certainly sterile processing plays a role in two major parts of that and we know that if the equipment is not properly clean, if it’s not functioning properly, that causes delays in the operating room, surgeon frustration goes up, there’s a toll on the staff. Toll on the staff and on the surgeon. I mean when you have a surgeon working on a patient, you want them to be totally focused on what they’re doing with the patient. You don’t want them to be distracted because of an instrument issue.
Gregg Agoston: Unfortunately, that occurs frequently and then it weighs on the surgeons. I was at a conference where a surgeon actually came in and gave a presentation where there was a problem with an instrument or first case of the day and then she’s thinking, well, what do I need to do to protect that patient? And now she’s thinking about that patient when she’s in with the next patient.
Todd Schlosser: Yeah. So it compounds. Yeah.
Gregg Agoston: It compounds itself. Exactly. And those frustrations build and surgeons become very, very frustrated when they can’t get equipment. They expect the equipment to be in the room, be available, be functional and be clean and sterile for every patient. That’s what they expect. The reality is, unfortunately that doesn’t always happen and we’ve got to try to fix that.
Todd Schlosser: And if fixing that is going to save billions and billions of dollars, of course across the country, not for every hospital but if you invest, whatever that hospital is, portion of that billions and billions of dollars in savings in the SPD. I mean it may not resolve every issue but you’re going to have a lot of resolution out of that.
Gregg Agoston: Well, that’s true. And then there’s the other area, Todd is repair and replacement of equipment. We know for a fact that a lot of the damage in hospitals and much of my career I was doing contracting for services again for major endoscopy companies and so I know for a fact that hospital spend exorbitant amounts of money fixing equipment. You could have a hospital with just one device called a ureteroscope. Okay. It’s a very thin scope, it’s used to go up the urator to look inside the kidney to do laces of kidney stones or diagnosis for cancer and other other procedures inside the kidney. That one instrument sells for about 15 to $20,000 a piece.
Gregg Agoston: They break very frequently and we know that a lot of damages that occurs to them just through mishandling in the sterile processing harbor again, because we’ve got everybody taking their turn, whether the person’s been there for months or they’ve been there for two weeks, they get their turn at cleaning these very delicate instruments and when you have a lot of instruments that look very heavy duties, big stainless steel instruments, things that you can kind of move around and get banged around, people think, well it’s steel, it’s okay. It’s not going to cause any damage.
Todd Schlosser: They assume it’s more durable than it is.
Gregg Agoston: They may assume it’s more durable and they cause damage and the repair of one of those is about a 10,000 … it could be anywhere from say 3,500 to $10,000 to fix one of those scopes. Hospitals a big teaching hospital could spend 3, $400,000 just on that one item and they may only have 10 or 12 of those in their whole inventory.
Gregg Agoston: It’s a major expense. Rigid scopes, camera equipment and even just stainless steel, it’s an education of how to properly handle. I mean, I’ve witnessed sterile processing staff take very delicate eye instruments and process after they washed them, they were pretty rough with them in the sink washing them and you’ve got these little delicate scissors that are cutting on the eye, taking them and banging them on the side of the sink to get the water off them at the end.
Gregg Agoston: I mean if you have somebody who’s uneducated about the instrumentation, you can do a lot of damage and hospitals will spend literally hundreds of thousands if not millions of dollars a year in repair equipment that probably 50 to 70% of it could be avoided through better-
Todd Schlosser: With just proper training.
Gregg Agoston: … through better training and education of their staff but the problem is in sterile processing, back to the original epidemic, people that are paid 12, $13 an hour, maybe they’re paid, they max out at like $22 an hour, and low, 40 range, lots of turnover. You could have hospitals that could have 20%, 30%, 40% turnover in a year and their staff and then they’ve got to start over and start training them again.
Todd Schlosser: Yeah. You’ve got that brain drain. Yeah.
Gregg Agoston: Brain drain, the tenure of the people, the knowledge of the people and all those people were handing over these equipment leads to damage so there’s major expense with that. Then also if they’re not processing it properly or not cleaning it properly and we leave behind any kind of bioburden, again, increased risk of surgical site infections for the patient. Some people think, well, if you put it in a sterilizer, sterilizer kills everything, right? Well, no. By definition-
Todd Schlosser: If it did you wouldn’t have a problem.
Gregg Agoston: If it’s not clean … Yeah, exactly. It’s like no one would go into a restaurant and pick a fork up that still had egg yolk hardened on it and say, “I’m going to just use this because it went through the sterilizer back in the back, right?
Todd Schlosser: Yeah. I would not.
Gregg Agoston: No. And you wouldn’t want that instrument if it was a scissor having blood or debris from a previous patient be used on you during your procedure.
Todd Schlosser: Absolutely. With this being the silent epidemic, as you’re saying, what can a company do or a hospital do if they’re having this problem with their SPD or with their surgical center?
Gregg Agoston: Yeah. I think the first thing is to recognize that the root cause of this issue, like a lot of hospitals will try to … sterile processing departments will treat symptoms. Like they’ll say, “Okay, we’ve got a high turnover. We need to recruit better. We need to maybe bump our pay a little bit.” Right?
Todd Schlosser: Sure.
Gregg Agoston: That still doesn’t solve the root cause of the problem. If they say, “Well, we’ve got surgeon frustration, we’re really going to focus, we’ll have an educator comment and really focus on this piece.” That one piece, I mean, while those are good efforts, it’s really addressing the symptoms of the problem and not the root cause. I think hospitals are well-advised to reach out and talk to companies such as ours. Other companies are out there as well that could come in and do consultations with them to really look for root cause of problems.
Gregg Agoston: The genesis I think is the fact that we know that without specialization, by not dividing your workforce, so to speak, within the hospital between complex in general instruments and small hospitals, I think some people say, “Well, we only have four ORs, we’ve got five people working here. How are we going to specialize?” What it really means is that you really need to have everybody being in that hospital, a specialist and look at pay and recognition and morale building and communication between OR and-
Todd Schlosser: And employee retention even. Yeah. Absolutely. Yeah.
Gregg Agoston: Well, that’s what I’m saying because without that in a small hospital, if you have a high turnover in a small hospital, it’s even worse because you don’t really have the opportunity to specialize. Everybody really has to handle everything but you really need more of that team approach between the OR and SPD and that’s a critical piece.
Gregg Agoston: I think looking at the root cause of the problems is a number one thing. Identifying places where specialization can occur to really provide a career opportunity for staff so that they can move in and many hospitals, you come in and sterile process you can get annual increases but there no designation between persons started yesterday and a person who’s been there for 5 years or 10 years. Nobody wants to work in that kind of environment. I think basically the SPD needs to come up into today’s world.
Gregg Agoston: SPD is a mass manufacturing area. Okay. The way it’s being run in a lot of hospitals today is being run like it’s more of a cottage industry because in essence the result, the end product that shows up in the operating room is the result of the one person who touched them. Many hospitals don’t even have an extra person QC product.
Todd Schlosser: QC be quality control. Okay.
Gregg Agoston: Quality control. Yeah. Where the person who packages the equipment and sterilizes it the one who pulls it to put it on the shelf and cart so there’s nobody like double checking. There’s not even a process for double checks periodically, like random. It’s not really … so the only way they know that something didn’t go right is when the operating room hollers down and says something’s wrong with this. You guys didn’t do this right and it can be really bad. I mean there’s patients that will go in and be under anesthesia or they’ve got to cancel cases because the instrumentation, they open it up and they find that there’s bioburden on an instrument and they don’t have another set. You’ve got a patient asleep and now the surgeon’s in a position where you can’t do the procedure, you’ve got a patient who’s undergone anesthesia, you’ve got a family that’s waiting to hear what’s going on and unfortunately the surgeon’s got to go out and tell them we had to cancel the case.
Gregg Agoston: I just heard of a case that happened the day before yesterday. A lot of that won’t show up on the front page of the newspaper but it happens in hospitals and if you talk to the people, that’s why I call it kind of a silent epidemic because it happens in hospitals across the country and quite frankly it’s an area that I think that if hospital administration focused on at more, if they recognize the root cause of those problems, it could be addressed and they would save money holistically through less damage, less repair replacement, less replacement of lost instruments. That’s another huge problem in the hospitals. All these other [inaudible 00:37:09], problems, delayed operating room times, the cost of operating room or just the fact that if I’m delaying this case, it means I can’t do another case. I can’t bring revenue in from another case. There’s a whole revenue side of this as well for hospitals.
Todd Schlosser: It’s a whole compounding issue.
Gregg Agoston: Yeah. You cannot look at this as being one single problem and it’s going to fix this and it’s all the problems go away. It’s a problem that’s really interrelated and again, when you look at the root cause, it’s a basically recognition of the value of importance of sterile processing by the hospital administration and allowing sterile processing to specialize to some degree like the operating room has so that you’re sure that you got your best people on to the most complex devices because when you don’t do that, if you could just graph this out, you’d see like an average person really good, you’re A player, you’re C player, well the best you’re going to be is B, right?
Todd Schlosser: Yeah.
Gregg Agoston: To the operating room, you’re a B. You’re never going to be an A, you’re never going to be a C, you’re going to be a B because you’re average. That’s the problem in the hospital. You’ve got to figure out a way to keep your A team on the complex stuff, let your B team be on the stuff that’s less complex and then that way you’re more sure that you’re going to have a better [inaudible] .
Todd Schlosser: And then train up to be on the A team. Absolutely.
Gregg Agoston: Absolutely. And give people opportunity for advancement.
Todd Schlosser: Yeah, absolutely.
Gregg Agoston: Yeah.
Todd Schlosser: Well, Gregg, this is a conversation we’re going to have to continue many, many times because there’s so much more I’d love to get into but we just sort of run out of time but thank you so much for taking time to talk to us today. I really appreciate it.
Gregg Agoston: Absolutely.
Todd Schlosser: Thank you again.
Gregg Agoston: My pleasure Todd.
Todd Schlosser: Absolutely.
Gregg Agoston: Thank you.