From the 2019 HVPAA National Conference
Mr. Samuel Eberlein (Cedars-Sinai Medical Center), Ms. Sarah Francis (Cedars-Sinai Medical Center), Ms. Maureen Fimpler (Cedars-Sinai Medical Center), Dr. Rodrigo Alban (Cedars-Sinai Medical Center)
Nearly 30% of all healthcare costs occur in the operating room1. There are no consensus best methods to reduce intraoperative expenses. Quality improvement studies often focus on process measures and health outcomes rather than costs.
This study examined variation and waste of disposable supplies and reusable instruments in eight general surgeons performing laparoscopic cholecystectomy (lap chole). After pooling cost data and determining factors responsible for variation, preference cards were standardized, and instrument trays were consolidated to reduce variation.
The study was carried out at a large, academic medical center, and it initially focused on an employed group of acute care surgeons. Supplies listed on each surgeons’ preference cards were uploaded to an Excel database. Supplies were flagged as removable if they appeared sporadically or if there was discrepancy between preference cards as to the number of supplies designated as “Open” or “PRN.” Potential for consolidation and elimination of less used supplies was reviewed with a member surgeon of the cohort, and those supplies were changed from Open to PRN or removed from the preference cards.
OR nurses and surgical technologists were then consulted on the feasibility of combining the previous two instrument trays into a single general lap chole tray while remaining under the 25-pound weight limit. Protocol sheets were analyzed to determine instruments that were not used or redundant and could be removed.
Relatively low variation was found across the eight pilot surgeons’ preference cards, primarily due to the homogeneity in practice of the physician group (acute care surgery team). Four different preference cards were slightly modified for minimal reduction in costs, but opportunities for standardization still exist both within the pilot group and the larger group of general surgeons practicing in the hospital. Nevertheless, the opportunity to combine separated endo tissue and lap chole instrument trays led to a net reduction of 12 instruments per tray and the elimination of one tray per preference card. This new tray is in circulation as of March 2019 for use in numerous general laparoscopic procedures (1,800 total cases in 2018). This consolidation is expected to reduce the number of instruments requiring sterilization processing each year by 21,600, increasing sterile supply capacity.
Instrument tray consolidation improves workflow and OR turnover by reducing the net washing, counting, and handling of instruments. Tray consolidation is ideal for high-volume, homogeneous, and short-duration cases as the accumulated daily reduction in turnover could create capacity for additional procedures. Although these cases have fewer disposable supplies overall, there is still opportunity to standardize and reduce variation. Complex cases stand to benefit even more from standardization due to the greater number of supplies utilized, the likelihood that redundant instrumentation has grown over time, and there is a tendency to open supplies that are not subsequently used.
The methods developed to standardize preference cards and consolidate instrument trays have significant potential to lower costs by reducing unnecessary instrument processing and disposable supplies.
1. Munoz, E., Munoz, W., 3rd, & Wise, L. (2010). National and surgical health care expenditures, 2005-2025. Ann Surg, 251(2), 195-200. doi:10.1097/SLA.0b013e3181cbcc9a