The choice between disposable and reusable airway management devices is more than a question of convenience, requiring consideration of patient- and practice-related factors as well as economic and environmental issues.
For P. Allan Klock Jr., MD, the switch to disposable laryngoscope handles and blades stemmed from reviewing Joint Commission standards for cleaning, disinfection and storage. “The crux of the matter is that we can no longer simply wash laryngoscope handles off after use anymore,” said Dr. Klock, professor of anesthesia and critical care at the University of Chicago. “We have to go through a formal, high-level disinfection, which is very time-consuming.”
Furthermore, this process involves harsh chemicals that have significant environmental impactand requires a substantial investment in infrastructure. The depreciation of capital equipment must be taken into account, he said, because this infrastructure breaks down over time and needs to be upgraded.
“Reusable devices are neither cheap nor easy,” he pointed out. “After disinfection, handles have to be reassembled, repackaged, stored and distributed before they can be used again.”
As Dr. Klock reported at the 2017 annual meeting of the Society of Airway Management, supply chain analysis of single-use laryngoscope handles at the University of Chicago showed that approximately $65,000 was spent on reprocessing costs alone each year. Capital costs, costs for sterilizing equipment and environmental impact were not included in this assessment. Moreover, Dr. Klock said, according to the value analysis, anesthesia technician labor comprised the majority of these costs, but this was significantly underestimated.
“Handling laryngoscope handles and blades was basically our technician’s full-time job,” Dr. Klock said. “We were also spending nearly $20,000 per year just to replace lost handles and blades.”
Based on these data, the University of Chicago converted to disposable blades and handles in its operating rooms. Although the supply cost of disposable equipment is now approximately $167,000 annually, Dr. Klock noted that this cost would be reduced by half if only the handles were replaced.
How Clean Are Scopes?
There are also patient factors to consider, especially with the use of flexible intubation scopes. Even with proper cleaning, Dr. Klock noted, a phenomenon called biofilm exists, which is a layer of protein building up on endoscopes.
“Handling of equipment is a significant issue for gastrointestinal procedures,” Dr. Klock reported. “New Joint Commission standards indicate that if a bronchoscope was removed from a patient more than an hour before being cleaned, it has to go through a high-level antiseptic soak for an hour. For endoscopes, on the other hand, it’s 10 hours.”
In addition, for patients with high-risk infections, such as bovine spongiform encephalopathy (mad cow disease), Creutzfeldt-Jakob disease or cystic fibrosis, multidrug-resistant Pseudomonas is a concern. “You have to wonder whether it’s worth reprocessing scopes that have those types of pathogens on them,” Dr. Klock said. “It’s probably better to use a single-use scope and then discard it.”
That’s not to say that all airway instruments should be disposable. At the University of Chicago Medicine, flexible intubation scopes and the GlideScope (Verathon), C-MAC (Karl Storz), LMA ProSeal and LMA Fastrach (Teleflex) are reused, whereas direct laryngoscopy blades and handles, and the LMA Supreme and LMA Unique (Teleflex), air-Q (Cookgas/Mercury Medical), and Pentax and King Vision (Ambu) scopes are single use.
Although Dr. Klock acknowledged concerns related to the additional waste generated by disposable devices, when compared with the total waste produced by operating rooms, the volume and environmental impact of disposable handles and blades are relatively minor.
Advantages of Reprocessed Devices
According to Kenneth P. Rothfield, MD, MBA, chief medical officer of Medical City Dallas, the FDA has known for more than 10 years that reprocessed devices are safe. When it can be validated that a device can be cleaned, tested and reused without harm to the patient, a device should be reprocessed, he said.
“Dr. Klock outlined the economics, but the reality is, if you’re throwing things away over and over again, it’s very expensive,” Dr. Rothfield said. “By using devices that can be cleaned and reused, you can capture additional revenue by reducing supplies expense. I also think the devices are better; they’re certainly a lot tougher and sturdier.”
Most importantly, Dr. Rothfield noted, single-use devices are bad for the environment. “U.S. health care contributes 4 billion pounds of waste annually, and the bulk of that medical waste is generated by disposable medical devices originating in the operating room. Anesthesia supplies are a big part of that.”
Nevertheless, Dr. Rothfield advocated for certain single-use devices. Given the threat to patient safety posed by hospital-acquired infections, the risk of reusing devices that can have errors in reprocessing is simply too great, he concluded.