James Farrelly (Yale University School of Medicine, Yale New Haven Children’s Hospital), Crystal Clemons (Yale New Haven Health System), Sherri Witkins (Yale New Haven Children’s Hospital), Walter Hall (Yale New Haven Health System), Emily Christison-lagay (Yale University School of Medicine, Yale New Haven Children’s Hospital), Doruk Ozgediz (Yale University School of Medicine, Yale New Haven Children’s Hospital), Robert Cowles (Yale University School of Medicine, Yale New Haven Children’s Hospital), David Stitelman (Yale University School of Medicine, Yale New Haven Children’s Hospital), Michael Caty (Yale University School of Medicine, Yale New Haven Children’s Hospital)
Healthcare spending in the US remains excessively high. Aside from complicated, large-scale efforts at health care cost reduction, there are relatively simple ways to decrease costs from everyday hospital operations. Our group sought to decrease the costs associated with surgical instrument processing within a large, multi-hospital health system.
The main objective for this clinical redesign project was the elimination of unnecessary instruments from surgical trays at Yale New Haven Children’s Hospital. Secondary objectives included surgeon satisfaction, decreased physical work lifting lighter trays, decreased purchasing and maintenance costs, decreased processing materials cost, and decreased labor costs for counting, decontaminating, and packing surgical trays.
This was a single-site observational study conducted at a large academic medical center. All surgeons within the section of Pediatric Surgery agreed to standardize the pediatric surgery trays and to eliminate instruments that were deemed unnecessary from each tray. A multidisciplinary start-up meeting was held, and this meeting included stakeholders from central sterile processing, operating room nursing, scrub technicians, and materials management along with all five pediatric surgeons. Each tray was addressed individually. Instruments were eliminated from trays only if there was unanimous agreement among all the surgeons in the group. If no instruments in a given surgical tray were deemed necessary, the entire tray was eliminated from sterile processing rotation. Feedback questionnaires were drafted by the multidisciplinary team that participated in the start-up meeting. Surgeons were allowed to request for certain instruments to be placed back into the trays at any time, and the questionnaires also allowed for free-hand comments. Surgical kit preparation time was obtained from the institutional barcode scanning system. The cost per second of sterile processing labor was calculated using regional median salary for sterile processing technicians in the state of Connecticut. Using the pediatric surgery section as the model unit, this method was then applied to pediatric urology, neurosurgery, spine surgery, and orthopedics.
The Pediatric Surgery section eliminated an average of 59.5% of instruments per tray, resulting in an overall reduction of 1826 (39.5%) instruments from rotation, 45,856 fewer instruments processed per year, and nine trays eliminated completely from regular rotation. Processing time for six commonly used trays was reduced by an average of 28.7%. The Urology section eliminated 18 trays from regular rotation and 179 (10.1%) instruments in total. Pediatric Orthopedics, Neurosurgery, and Spine sections eliminated 708 (17.1%), 560 (92.7%), and 31 (32.2%) instruments, respectively, resulting in approximately 18,804 fewer instruments processed per year. Among all five surgical sections, annual instrument cost avoidance after tray optimization was about $53,193 to $531,929 using average instrument life spans ranging from 1-10 y. Negative feedback and requests for instrument replacement were both minimal on feedback questionnaires.
Surgical tray optimization represents a relatively simple microsystem improvement that could result in significant hospital cost reduction. Although difficult to quantify, other gains from surgical kit optimization include decreased weight per tray, decreased materials cost, and decreased labor required to count, decontaminate, and pack surgical trays.
Implications for the Patient
Cost-effective, efficient perioperative instrument management will result in lower operating costs, which should result in lower costs for surgical patients. Optimized surgical trays might result in shorter counting times, faster turn-around time, and shorter, safer surgeries for patients.