Reducing Operating Room Cost: Comparing Attending and Surgical Trainee Perceptions About the Implementation of Supply Receipts.

BACKGROUND: As operating room (OR) expenditures increase, faculty and surgical trainees will play a key role in curbing future costs. However, supply cost utilization varies widely among providers and, despite requirements for cost education during surgical training, little is known about trainees' comfort discussing these topics. To improve OR cost transparency, our institution began delivering real-time supply "receipts" to faculty and trainees after each surgical case. This study compares faculty and surgical trainees' perceptions about supply receipts and their effect on individual practice and cultural change. STUDY DESIGN: Faculty and surgical trainees (residents and fellows) from all adult surgical specialties at a large academic center were emailed separate surveys. RESULTS: A total of 120 faculty (30.0% response rate) and 119 trainees (35.7% response rate) completed the survey. Compared with trainees, faculty are more confident discussing OR costs (p < 0.001). Two-thirds of trainees report discussing OR costs with faculty as opposed to 77.0% of faculty who acknowledge having these conversations (p = 0.08). Both groups showed a strong commitment to reduce OR expenditures, with 87.3% of faculty and 90.0% of trainees expressing a responsibility to curb OR costs (p = 0.84). After 1 year of implementation, faculty continue to have high interest levels in supply receipts (82.4%) and many surgeons review them after each case (67.7%). In addition, 74.3% of faculty are now aware of how to lower OR costs and 52.5% have changed the OR supplies they use. Trainees, in particular, desire additional cost-reducing efforts at our institution (p < 0.001). CONCLUSIONS: Supply receipts have been well received and have led to meaningful cultural changes. However, trainees are less confident discussing these issues and desire a greater emphasis on OR cost in their curriculum.

[Reduced climate impact by resource-efficient surgeries]. / Resurssmarta operationer för lägre klimatpåverkan - Projekt i Västra Götalandsregionen minskade avfallet samtidigt som arbetet blev effektivare.

The Västra Götaland region carried out a project to develop resource-efficient surgeries using standardized hip prosthesis surgery as case. The purpose was to reduce and streamline the use of consumables and thus reduce the climate impact. At the surgery departments of three hospitals, significant variations were found in the supply and use of consumables during operations for total hip replacement (5.0-6.6 kg dry weight/operation). The major part of disposables consisted of surgery textiles, and choosing fossil-free products has the beneficial impact on a carbon footprint. Customized surgical procedure trays significantly reduce the number of packages and result in reduced work load for the staff. However, since there is a long term trend to increase the use of consumables in such sets, there is a need of continuous monitoring of such choices. In summary, a critical review of routines for care and use of materials is a powerful tool for streamlining healthcare and reducing its climate impact.

Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

BACKGROUND: With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes. STUDY DESIGN: Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level. RESULTS: There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001). CONCLUSIONS: In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

Prevention of medical accidents caused by defective surgical instruments.

BACKGROUND: The malfunctioning of surgical instruments may lead to serious medical accidents. Limited information is available on the risk of defective instruments. The purpose of these study is to demonstrate the features of defective surgical instruments, to establish a strategy to reduce the risk of medical accidents. METHODS: We studied 19,474 consecutive operations during 2007 to 2009 at our hospital. The data on defective instruments were collected based on the orders for repair of broken instruments and reports of near-miss incidents. Adverse events caused by defective instruments were also identified from reports of near-miss incidents. RESULTS: A total of 1,775 nonfunctioning instruments were identified during the study period. Of these, 112 were found during operation. More than half of the defective instruments were tissue-grasping instruments, bone-boring/gnawing instruments, and instruments for endoscopic surgery. Wearing out and inappropriate use of instruments were 2 major causes of defects. The rest of the causes consisted of inadequate inspection and factory defects. Two near-miss incidents (incidence 10 per 100,000 operations) in endoscopic surgery were potentially critical, but the postoperative course was uneventful in each patient. The incidence of defects adjusted by the number of operations demonstrated that bone-boring/gnawing instruments and instruments for endoscopic surgery tend to be broken during surgery. Without inspection by the manufacturer, the incidence would be much higher for endoscopic instruments. CONCLUSION: Our data suggest that the appropriate use and adequate inspection of particular types of instruments are key for reducing the risk of medical accidents caused by defective surgical instruments.

Reducing medical waste.

Medical waste is a necessary by-product of any hospital environment; however, the majority of regulated medical waste is produced in the OR from the use of disposable surgical supplies (eg, drapes, gowns, basins, gloves, sponges). We conducted a concept comparison project in the ORs of two large medical centers in Bethesda, Maryland, and Washington, DC, to evaluate the effects of using reusable surgical basins, gowns, and table and Mayo stand covers in place of disposable products. Survey results indicated that surgeons and surgical technologists found the reusable products to be preferable to the disposable products currently in use. In addition, using reusable products provided a means to decrease regulated medical waste generated in the OR by an average of 65% as well as reduce the cost of waste disposal. AORN recommends evaluating the environmental effects of using reusable, reposable, and disposable products; our findings provide evidence that may be useful to surgical facilities that seek to adopt a "green" approach.

Can efficient supply management in the operating room save millions?

PURPOSE OF REVIEW: Supply expenses occupy an ever-increasing portion of the expense budget in today's increasingly technologically complex operating rooms. Yet, little has been studied and published in the anesthesia literature. This review attempts to bring the topic of supply management to anesthesiologists, who play a significant role in operating room management. RECENT FINDINGS: Little investigative work has been performed on supply management. Anecdotal reports suggest the benefits of a perpetual inventory system over a periodic inventory system. A perpetual inventory system uses utilization data to update inventory on hand continually and this information is linked to purchasing and restocking, whereas a periodic inventory system counts inventory at some regular intervals (such as annually) and uses average utilization to set par levels. SUMMARY: On the basis of application of operational management concepts, ways of taking advantage of a perpetual inventory system to achieve savings in supply expenses are outlined. These include linking the operating room scheduling and supply order system, distributor-driven just-in-time delivery of case carts, continual updating of preference lists based on utilization patterns, increasing inventory turnovers, standardizing surgical practices, and vendor consignment of high unit-cost items such as implants. In addition, Lean principles of visual management and elimination of eight wastes may be applicable to supply management.

Actual and estimated costs of disposable materials used during surgical procedures.

It is difficult to estimate precisely the costs of disposable materials used during surgical operations. To evaluate the actual costs of disposable materials, we calculated the actual costs of disposable materials used in 59 operations by taking account of costs of all disposable materials used for each operation. The costs of the disposable materials varied significantly from operation to operation (US$ 38-4230 per operation), and the median [25-percentile and 75-percentile] of the sum total of disposable material costs of a single operation was found to be US$ 686 [205 and 993]. Multiple regression analysis with a stepwise regression method showed that costs of disposable materials significantly correlated only with operation time (p<0.001). Based on the results, we propose a simple method for estimating costs of disposable materials by measuring operation time, and we found that the method gives reliable results. Since costs of disposable materials used during surgical operations are considerable, precise estimation of the costs is essential for hospital cost accounting. Our method should be useful for planning hospital administration strategies.

Reprocessing single-use medical devices.

Health care providers today often can choose between reprocessed single-use devices (SUDs) or SUDs from original equipment manufacturers. The concern about whether reprocessing is safe and should continue was reflected in the US Food and Drug Administration's draft regulations regarding reprocessing and reuse of SUDs; the Government Accounting Office study on SUDs; legislation introduced at both the federal and state levels; and Congressional hearings by the US House of Representatives and the US Senate. This article offers a review of these activities.

OR barrier materials--necessity or extravagance?

The issue at hand, therefore, is not one of reusable versus disposable, but rather the cost-effectiveness and expense associated with use of barrier versus nonbarrier materials. As mandated by the Occupational Safety and Health Administration, the need and function of the surgeons' gown barrier is a given. Initially the gown was used to protect the patient from members of the surgical team; its role now is to protect the surgical team members from the patient and the hazards associated with exposure to bloodborne pathogens. As for barrier drapes (i.e., patient, Mayo stand, back table covers), considering the influence of today's antibiotics and the advent of minimally invasive surgical techniques on the incidence of postoperative infection, just how necessary are they? Initially the use of barrier drapes was viewed as a reasonable practice. The problem, however, with any reasonable type of practice of this nature is identifying the kind and quality of supporting evidence and testing the practice itself. If there is no evidence for or against a practice; its advocates make up the process as they go along. In the case of barrier drapes, there were individuals who assumed that there were studies that conclusively demonstrated their need, even though they never sought confirmation to that effect. In the process, whether the drapes were cost-effective escaped criticism, and their use survived over the years because of the "that's the way we've always done it" syndrome. In a comprehensive examination of draping practices written 60 years ago, a physician discusses the myriad sources of contamination that could contribute to postoperative infection. He concluded that "to minimize the chances of contamination, all of these sources must be separately and individually studied." In terms of the influence of barrier surgical drapes, there remains a need for unbiased, statistically valid, conclusive research. Until such data become available, their use cannot be indisputably defended.

Focused versus operating room-wide recovery of unused supplies for overseas reconstructive surgery.

Proliferation of programs that recover surplus operating room supplies may effectively address the needs of volunteer overseas surgical efforts. However, these programs tend to garner supplies highly heterogeneous in nature. In order to evaluate the nature and quantity of supplies generated by plastic and reconstructive procedures, we extrapolated the inventory of 71 consecutive cases from our 33,000-case database. Additionally, we examined the recovery of 7 specific supplies from all cases performed at Yale-New Haven Hospital over a 3-year period. Though consistency is unlikely when only plastic and reconstructive surgical cases are examined, operating room-wide recovery may be a reliable source of usable materials.

Case-by-case assessment of recoverable materials for overseas donation from 1318 surgical procedures.

OBJECTIVE: To provide a mechanism for addressing the need for consistency and projection in overseas donation of surgical supplies, we conducted a case-by-case inventory of unused materials recovered from all surgical procedures in our facility over a 2.5-month period. DESIGN: Unused surgical supplies were recovered in coded bags from individual cases and inventoried. SETTING: Inpatient operating rooms at Yale-New Haven Hospital. MAIN OUTCOME MEASURE: The weight and dollar value of recovered materials were tallied for each case type; these were then extrapolated according to the frequency with which each procedure is performed in the United States to provide an estimate of the impact of a nationwide recovery program. RESULTS: The value of supplies recovered ranged from $1 (bone marrow transplant) to greater than $40 (liver and vulva/perineum procedures). By extrapolation to case-specific data from the National Hospital Discharge Survey (1990), we estimate that a nationwide recovery program could yield more than $193 million in charitable material and reduce operating room waste by more than 1.7 million kilograms (1948 tons). CONCLUSIONS: Consistency and organization would contribute greatly to efforts to alleviate existing medical supply needs in the developing world. This case-by-case assessment should enable participating centers to project more effectively the outcome of such collections and allow the coordination of efforts. Though unlikely to be adopted by all operating theaters in the United States, the potential charitable contributions from a nationwide recovery program are significant.