To the Editor

I have read with interest over the yeas the ongoing debate about the reuse of “disposable” medical equipment as discussed at various times in your newsletter.

It seems to me that the debate has never taken place in a forum that had as its central intent effective cost containment or reduction without incurring patient risk.

Advocates of approaching the rational reuse of some “disposable” single-use products always seem to fall victim to some “horror stories” of examples in which products which should never have been considered for reprocessing and reuse. Often these were obviously reprocessed in either a derelict of defective manner and are held up as examples of what will happen if any reprocessing of “disposable” medical products is allowed. Obviously, spokesmen for the “Disposable Medical Products” industry and those professionals who may be in their direct or indirect employ have much to gain from promoting these horror stories. I also have great distrust of the various government affiliated agency pronouncements on this subject. All too often, I have found government agency pronouncements too heavily influenced by the “politically correct” posturing of the day. Some of these government agencies rely on ill conceived and outdated concepts which have been canonized in the medical literature, often with the assistance of the very “Disposable Medical Products” industry they ought to be confronting. If this were not enough to overrule rational thought, then the shibboleth of “Exposure to Medical-Legal Liability” is usually brought out to complete the task.

Balancing Motivations

I know of no alternative agenda or self serving goals that motivates those medical professionals who advocate sensible reuse of disposable products, other than reducing the cost of medical care, and perhaps stabilizing the financial aspects of their institution. I guess that on e could invoke the specter of the avaricious medical facility that would wantonly reuse expensive invasive devices to increase profit, but in my practice history, that example is rare to non-existent. A much more common profile, in my experience, is that of a medical manufacturer who labels easily reprocessed devices as “single use only – do not reuse” in order to enhance sales volume and profit.

In 25 years of active practice in anesthesia, in both the private and academic sectors, I have observed tremendous and thoughtless waste of medical supplies by anesthesiologists, surgeons, OR nurses and other OR personnel. I have made this observation in the private practice, academic practice, and US military practice portions of my career.

It seems to me that the discussion ought to start at the simplest level and proceed from there to the more complex. Too often, discussion begins at the most complex level, and the simpler levels are never reached or discussed.

Recommended Recommendations

There are obvious differences in levels of patient risk in this issue. Those instances of lowest risk to patients should be addressed first, and recommendations developed.

For example:

1. Items which are used only in external contact with the patient such as headrests, arm, elbow, neck cushions, orthopedic tourniquets, blood pressure cuffs, pressure bags used to administer blood and IV fluids, pulse oximetry probes are examples of devices which are often marketed as single items with the admonition printed on them, “single patient use only – do not reuse.” I have to question anyone who doubts that these expensive items cannot be safely reprocessed for subsequent reuse. However, institutions that do so are placed at risk b the current medical phobia regarding the reuse issue.
2. Items that are in minimal internal contact with patient, (face, nasal passage, oropharynx) and whose design and construction are of such that a very smooth, easily cleaned surface renders them candidates for reuse, are routinely discarded. These would include items such as nasal airways, (an identical product in a multi-use form is often used), oral airways, face masks for anesthesia circuits, esophageal stethoscopes with and without temperature probes. It is true that these times are in contact with mucosal surfaces, and thus require adequate cleaning and sterilizing between use, but their construction renders this easily and economically done. I’m sure that a small amount of effort could expand this list greatly.
3. All too often the “cost” of reprocessing in used as an excuse or rationale for discarding some of these high volume disposable items. In many cases this is truly a straw issue. Much of the sterilizing and reprocessing can be easily accomplished by personnel already on the payroll, during times when other work requirements are low. Having an adequate inventory of these products so that soiled products can be stored and cleaned during less busy times, and an accessible inventory of sterile reprocessed products available greatly weakens the arguments regarding “reprocessing costs.”
4. Products which are fragile, or subject to breakage or a weakening during reprocessing, or which are used in IV invasive procedures or other parenteral usage, or of a design that thorough cleaning is difficult or questionable, are products which require much more investigation and study. They may well prove not to be viable candidates for reuse. However, most of the focus of the debate centers in this category alone, and meanwhile, millions and millions of patient care dollars are wasted because concerns about items in this category preclude rational discussion of categories 1 and 2 above.

Evaluating Motivations

In summary, the debate seems to take place with the primary participants either government functionaries interested in expanding their ability to promulgate regulations, or those who are either directly or indirectly in line to benefit from the “Disposable Medical Industry.” As in other examples of government-industry regulation, there often exists areas of overlapping self interest and questionable objectivity. Scant attention is granted people who work in a hands-on clinical situation who have a wealth of experience in observing this great financial wastage, and whose experience might well serve as a better guide regarding which items to consider for reuse and which not, than those currently in the center of the debate. These hands-on individuals often are left out as they lack any self enhancing economic motivation, and are often bereft of the resources to compete at the same level of the other participants in the discussion.

Perhaps the APSF Newsletter could request practitioners to submit their suggestions of items in the categories 1 and 2 above. Then a discussion focused on the pros and cons of reuse of these items could take place.

Clair S. Weenig, M.D. Anesthesiologist, private practice 20 years Academic practice 3 years US Navy Anesthesiologist 2 years Assistant Clinical Professor Anesthesia, University of California Medial Center, San Francisco, CA