(Chest. 2005;127:1382-1387.)
© 2005
American College of Chest Physicians
Reducing Maintenance and Repair Costs in an Interventional Pulmonology Program*
William Lunn, MD, FCCP;
Robert Garland, RRT;
Lorraine Gryniuk, RRT;
Laureen Smith, RN;
David Feller-Kopman, MD and
Armin Ernst, MD, FCCP
* From the Interventional Pulmonology Department, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, BIDMC, 330 Brookline Ave, Boston, MA 02215; e-mail: aernst{at}bidmc.harvard.edu
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Abstract
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Background: In the current economic climate, hospitals and academic institutions demand that medical departments function in an efficient and cost-effective manner. Detailed business plans are necessary to build new clinical programs, and institutions have learned that new programs are associated with significant costs for purchasing and maintaining equipment. We report our experience with repairs to equipment before and after starting our interventional pulmonary (IP) program, and with the effect of an educational program on reducing these costs.
Methods: We retrospectively studied the costs of equipment repair in the 3 years preceding and in the 5 years following the development of an IP program in our institution, a university-based tertiary referral center. We also studied the effect of an educational program that was designed to enhance the skills of physicians and technical staff in handling the equipment.
Results: The cost of repairs to the equipment during the 3 years prior to the development of the IP program was $42 (US dollars) per procedure. In the initial 3 years following the start of the IP program, the yearly average cost rose 21% to $51 per procedure. After the introduction of the educational program, the yearly repair costs decreased by 84% to $8 per procedure. Based on our experience, we estimate that a reasonable budget for the cost of repairs is $50 per procedure.
Conclusions: An educational program was effective in dramatically decreasing the costs of equipment repair after initiating an IP program. This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.
Key Words: bronchoscope • budget • education • equipment damage • interventional pulmonology • repair • training
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Introduction
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Interventional pulmonology (IP) is an emerging field in pulmonary and critical care medicine that places an emphasis on the use of minimally invasive endoscopic procedures and new technology to diagnose and treat conditions in the chest.123 The equipment employed by physicians in this discipline is prone to damage due to the nature of the procedures being performed (eg, laser bronchoscopy, electrocautery, and endoscopic needle biopsy) and the delicacy of the technology (eg, flexible endoscopes and endoscopic ultrasound transducers). It is well-known, for example, that transbronchial needle aspiration (TBNA) biopsy performed with a flexible bronchoscope (FB) may result in damage to the scope.4567
It is now a reality in both private and academic settings that detailed business plans are necessary when planning to implement new clinical programs, to grow preexisting programs, or simply to maintain the status quo. There is a paucity of data in the literature that would allow a bronchoscopy unit director or a hospital administrator to develop such a plan for creating an IP program. In order to gain a foothold in estimating the anticipated repair and maintenance costs of developing an IP program, we report our experience with these issues over the last 8 years. Moreover, we propose methods for controlling costs and provide budgetary guidelines for anticipated repairs.
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Materials and Methods
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We conducted a retrospective review of the repair costs for endoscopes and associated equipment at our institution, which is a university-based tertiary care referral center, before and after the inception of the IP program. It is important to note that our study examines the experience of our entire pulmonary division, of which the IP section was a part beginning in 1999. While our general pulmonary colleagues perform a full range of diagnostic bronchoscopy, including TBNA biopsy, our IP section performs a host of other diagnostic and therapeutic procedures. The specific procedures performed by the IP section include the following: flexible and rigid bronchoscopy; Nd-YAG laser; argon plasma coagulation; electrocautery; cryotherapy; photodynamic therapy; autofluorescence bronchoscopy; microdebrider bronchoscopy; stent placement; catheter placement for endobronchial radiation therapy; endobronchial ultrasound; TBNA biopsy; tracheotomy; thoracoscopy; and percutaneous endoscopic gastrostomy tube placement.
Repair logs were, and continue to be, meticulously maintained by our technical director (R.G.). These records specified the complaint triggering the repair, the third-party report of the problems discovered, the repairs made, and the costs of the repairs. Any definition of preventable equipment damage would be somewhat arbitrary. Some normal "wear and tear" will occur in all equipment that is used on a regular basis. Scratched lenses, dented outer sheaths, and worn switches would likely be considered to be normal wear and tear for FBs. Preventable damage is probably best thought of as damage occurring as a result of improper handling. For example, unsheathing a biopsy needle in the working channel of the FB, firing an electrocautery snare inside the working channel of the FB, and failing to employ a bite block in a patient undergoing bronchoscopy orally through an endotracheal tube who then bites down on the tube and damages the FB. We estimated our preventable repairs based on the criteria cited above. We arbitrarily classified damages as major if repair costs were 
$1,000 (US dollars) and minor if repair costs were < $1,000. We compared the cost of repairs to endoscopes and equipment for the preceding 3 years prior to the inception of the IP program and for the subsequent 5 years following its inception. After analyzing our data, we created an annual budget for repairs. Additionally, we estimated the cost of repairs to equipment that an institution may encounter based on our experience.
We also compared the costs of repairs following the initiation of an educational program for physicians and technical staff that was designed to improve the handling of endoscopes and equipment. This aforementioned program, introduced in July 2002, took the form of a 1-day introductory course in bronchoscopy and IP at our institution. The curriculum required faculty, fellows, and technical staff to become proficient in the equipment they would be handling during the procedures.
The course was composed of the following two core components: (1) a didactic session with lectures followed by audience questions and discussion; and (2) a laboratory session with "hands-on" workstations to practice performing procedures with the equipment under the guidance of an experienced clinician. An integral part of the laboratory session involved the attendees rotating through a training center that employed intubating mannequins, endoscopes, and a virtual reality flexible bronchoscopy simulator (Immersion Medical; Gaithersburg, MD). While one lecture in the didactic session reviewed interventional techniques such as rigid bronchoscopy and thoracoscopy, the workstation sessions focused on flexible bronchoscopy and airway management. Both the didactic and hands-on sessions stressed the importance of safety regulations, procedures (ie, proper sheathing of TBNA biopsy needles), and proper cleaning techniques. All staff, including technicians, fellows, and attending physicians, were allowed to perform procedures in patients only after demonstrating proficiency in the training center.
The educational program was continued on an annual basis. Weekly reviews of procedure-related complications are conducted, and issues of equipment mishandling identified. In such cases, staff was reeducated regarding the proper handling of equipment. The costs of implementing the educational program have averaged about $3,000 per year. These costs have been incurred in producing the course books that are given to each participant, in providing a meal and some refreshments during the day to participants and staff teaching the course, and in providing travel honoraria for invited speakers from other institutions.
There were no other interventions during this time period other than the educational program. Specifically, there were no changes in our repair contracts, no alterations in our cleaning and maintenance protocols for equipment, no changes in our sedation or monitoring practices, and no attempts to limit physician or staff privileges besides the requirement that they complete the education program as described above. One new faculty member was brought in as an additional full-time interventional pulmonologist in July 2002 but had been an interventional fellow in our program from July 2001 to June 2002. Additionally, four new pulmonary faculty members were added to the division from 1999 to 2003, none of whom had expertise or training in interventional pulmonary techniques, to function as general pulmonologists. Finally, no new technical or nursing staff was added during the time frame of the study.
The average age of the equipment did not change during the time frame of the study. Older FBs were replaced with newer models as follows: four new video FBs were purchased in 2001; and two new video FBs were purchased in 2002. Our equipment inventory from 1999 to the present was as follows: 2 sets of rigid thoracoscopes; 4 sets of rigid bronchoscopes and telescopes; and 15 flexible video bronchoscopes. Additionally, we obtained two semirigid video thoracoscopes in 2001 and one flexible video esophagoscope in 2003. We did not employ a formal replacement protocol or schedule for replacement. Our technical director recommended equipment replacement once a particular instrument began having the need for repeated adjustment and maintenance. Our endoscopic equipment was cleaned in an automated washer after each procedure and then was placed in a dryer before the next use.
Finally, we performed a statistical analysis of our data using the Fisher exact test. Specifically, we wished to compare our rate of all repairs and of preventable repairs during the baseline period before the formation of the IP program, from 1996 to 1998, to the first 3 years of the IP program prior to the introduction of the educational program from 1999 to 2001. We then performed an identical analysis of all repairs and preventable repairs during the period 1999 to 2001 and the period after the introduction of the educational program, from 2002 to 2003.
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Results
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Repairs to equipment averaged $8,197 per year during the 3-year period prior to developing the IP program at our institution (Table 1
). The average cost of repairs was $42 per procedure during this time frame.
In contrast, the cost of repairs averaged $35,148 per year during the first 3 years of the IP program (Table 2
). The increase in repair costs translated into an average cost of $51 per procedure during this time frame, which was a 21% increase in costs from baseline.
When the educational program was launched in July 2002, repair costs dropped significantly. The average repair cost per year fell to $10,464, resulting in a cost per procedure of $8. This represented an 84% drop in the cost of repairs. These reduced costs were realized despite an average 10% increase per year in the number of procedures being performed during this time frame.
The specific types of repairs ranged from replacing a malfunctioning video lens in an FB to totally refurbishing an FB that had been damaged by a misfire during argon plasma coagulation treatment (Table 3
). All of the episodes of equipment damage occurred during the course of performing procedures. We did not experience damage due to improper storage or cleaning of our instruments.
Endoscopic surgical equipment is expensive to purchase and to maintain. We conducted an informal survey of medical equipment suppliers over the Internet and found that FBs, excluding the processor and monitor, may be purchased new for $10,000 to $25,000 and used for $3,000 to $10,000. Analyzing our own data, we found that maintenance costs may range from $100 to repair dents in the outer sheath of an FB to $7,200 for major refurbishment of an FB (Table 4
). The number of procedures per year and the associated number of repairs are listed in Table 5
.
Tables 6
and 7
detail the comparisons between the baseline period, 1996 to 1998, before the formation of the IP program and the period before the introduction of the educational program, 1999 to 2001. There were 14 total repairs, 8 of which were deemed preventable, during the period 1996 to 1998, and there were 57 total repairs, 26 of which were preventable, during the period 1999 to 2001. While the absolute number of repairs increased during the period 1999 to 2001, the number of repairs as a percentage of the total number of procedures performed did not change significantly.
Tables 8
and 9
detail the comparison between the period 1999 to 2001 and the period following the introduction of the educational program, 2002 to 2003. There were 17 total repairs, 5 of which were deemed to have been preventable, during 2002 to 2003. Not only did the total number of repairs decrease during the period 2002 to 2003, but also the number of repairs as a percentage of the total number of procedures performed decreased significantly compared to those in the period 1999 to 2001.
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Discussion
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Although procedures to diagnose and treat thoracic conditions are commonly performed in the United States, little has been written about the costs of the repair and maintenance of endoscopic surgical equipment. In 1990, Mehta et al8 described their experience at the Cleveland Clinic with damage and repair costs to FBs. At the time, these investigators reported that they were performing an average of 900 bronchoscopies per year for both diagnostic and therapeutic purposes. Mehta et al8 experienced the following several types of FB damage: broken quartz fibers and outer sheath due to a patient biting the FB; perforation of an inner channel by a transbronchial needle; burning of the distal end of an inner channel due to the withdrawal of a hot laser fiber tip; and damage to an outer sheath due to improper ethylene oxide gas sterilization. All of this damage resulted in annual repair costs averaging $20,000. This results in a repair cost of approximately $22 per procedure. After a careful analysis of each episode of damage, these investigators determined that 87% of the equipment damage was preventable. They concluded that proper education of physicians and technical personnel would be desirable to prevent unnecessary repairs, but no particular intervention was studied.
In 1992, Kirkpatrick et al9 at the University of South Alabama reported results from a study that they conducted on FB damage in institutions in their surrounding area. These investigators performed a postal survey of hospitals in Alabama, Mississippi, and Louisiana that had performed an average of 233 bronchoscopies per year. Of the 43 completed surveys, there were a total of 103 episodes of bronchoscope damage with an average repair cost of $2,726.13 per episode. The respondents reported that 64% of the episodes of FB damage were preventable. Kirkpatrick et al9 concluded that the education of personnel handling an FB should help to decrease the frequency of equipment damage and to limit repair costs.
Our experience with equipment damage and repair mirrors that of Mehta et al8 and Kirkpatrick et al.9 Our IP department was created in 1999 and has engaged in training IP fellows since 2000. As detailed above, we perform a full array of diagnostic and therapeutic thoracic procedures in our hospital. As our IP department grew and the volume of procedures increased, so did the volume of repairs to equipment (Table 5). The baseline cost of repairs per procedure went from $42 to $51 before the initiation of our educational program. The effect of the training program was significant, with repair volume diminishing and the cost per procedure dropping to an all-time low of $8 during the following 2 years, despite a 10% increase in the number of procedures that were performed. There was a dramatic impact in decreasing the number of preventable repairs.
In 2001, Colt et al10 reported that a training program for novice bronchoscopists utilizing a virtual reality simulator increased dexterity and the quality of the examinations performed on a simulator. These investigators did not comment on whether this program reduced the cost of repairs to equipment once the bronchoscopists began performing procedures on patients. Similarly, Ost and colleagues11 performed a multicenter prospective study evaluating the utility of a bronchoscopy simulator in training new pulmonary fellows to perform bronchoscopy. They found that the simulator training improved bronchoscopy skills on the simulator and in actual patients. The simulator’s impact on damage and repairs to equipment was not studied. The present study is the first, to our knowledge, to prove the benefit of an educational program including virtual training in reducing repair costs.
It is possible that medical centers engaged in training IP fellows might experience higher repair costs to equipment. It is interesting to note that equipment damage increased during the same year that the interventional pulmonary fellowship-training program began at our institution. It stands to reason that a person learning the procedures would be more likely to mishandle the equipment than a person with extensive experience and training. Recently, there has been debate in the literature1213 as to whether or not formal IP training is necessary, but supervised formal training may certainly help to keep equipment repair costs under control.
Obviously, the maintenance and repair costs of equipment are only part of the story when one considers budgeting for an IP program. Typically, a physician with special experience and training must be recruited and hired. A dedicated nurse with ICU experience is often an asset to assist the IP physician with complex and high-risk airway procedures, postoperative care, and patient education. More respiratory therapists may be required as the volume of flexible bronchoscopy and other procedures grows. Finally, new equipment may need to be purchased in order to keep up with clinical volume and to offer procedures using unique treatment modalities, such as photodynamic therapy.
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Conclusion
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Interventional pulmonologists utilize delicate equipment and expensive technology to perform procedures on acutely and chronically ill patients. During the course of time, the equipment may become damaged or even mishandled, resulting in costly repairs. Among many other costs, equipment damage must be budgeted for in any IP program, and we think that a repair cost of $50 per procedure would be a conservative estimate from which to start in the United States. We believe that an educational program for physicians and technical support staff, as well as dedicated training in the field of IP, is useful to help to curtail equipment repair costs.
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Footnotes
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Abbreviations: FB = flexible bronchoscope; IP = interventional pulmonology; TBNA = transbronchial needle aspiration
Received for publication March 25, 2004.
Accepted for publication September 2, 2004.
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References
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Abstract
Introduction
