[Implementing an operating room pharmacy satellite in an university hospital]

OBJECTIVES

An operating room pharmaceutical unit centralizes medical devices and drugs for various surgical specialities. The aim of this work is to present the methodology used in our establishment to set up the operating room pharmaceutical unit.

METHODS

This approach involved the formation of multi-professional working groups. The needs of operating theatres were defined based on an analysis of healthcare product consumption and stock inventories. Material sheets were defined for each procedure. On the basis of simulations, material supply arrangements were selected, specifying material flows, equipment, workstations and information systems.

RESULTS

Over 3200 healthcare product references were identified and 862 equipment files were created. Local stocks have been limited to medical trolleys for nursing staff. Emergency operating packs have been deployed for unforeseen operations. Cabinets have been dedicated to transporting re-sterilizable medical devices, and carts have been purchased for programmed operating packs. The equipment is made available by logistics agents and pharmacy assistants under pharmaceutical responsibility.

CONCLUSIONS

This innovative approach is a model for facilities desiring to centralize and secure the logistics of healthcare products in the operating room. Ongoing adjustments will be required to meet new operating rooms needs.

Improving sustainability and mitigating the environmental impacts of anaesthesia and surgery: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change.

Interventions to Reduce Surgical Waste Burden: A Systematic Review

Background

Operating suites are significant drivers of waste, pollution, and costs. Surgeons can help fight the climate crisis by implementing innovative strategies aimed at mitigating the environmental impact of surgical procedures and decreasing operational costs, and moving toward a more sustainable healthcare system. This study aims to review the literature describing interventions that reduce surgical waste.

Methods

PubMed, Cochrane, and Embase were searched. Studies reporting interventions to reduce operative waste, including emissions, energy, trash, and other, were included. Case reports, opinion-based reports, reviews, and meta-analyses were excluded. Study quality was rated using MINORS and Jadad scales. Data were extracted from each study to calculate waste on a per case basis. Narrative review of studies was performed rather than meta-analysis.

Results

The search yielded 675 unique hits, of which 13 (level of evidence: I-III) met inclusion criteria. Included studies were categorized by intervention type in relation to the operating and procedure room. Three studies evaluated provider education initiatives, three evaluated setup of instruments, two evaluated single-use items, four evaluated technique changes, and one evaluated surgical venue. Seven studies reported significant reductions in disposable surgical waste throughput, and seven reported significant reductions in cost.

Conclusions

The results of this systemic review demonstrated the effectiveness of surgical waste reduction initiatives in reducing waste volume, cost, and carbon emissions. Within plastic surgery, minimal surgical packs resulted in reduced gross waste and cost while promoting patient satisfaction in hand surgery, supporting the continued development and implementation of such initiatives in a surgical context.

The accuracy of preoperative implant size prediction achieved by digital templating in total knee arthroplasty is not affected by the quality of lateral knee radiographs

Background

Digital templating software can be used for preoperative implant size prediction in total knee arthroplasty (TKA). However, the accuracy of its prediction is reported to be low, and the impact of radiograph quality is unclear.

Purpose

To investigate on the application of lateral knee radiograph quality criteria for knee rotation (KR) and knee abduction/adduction (KA) and their impact on the accuracy of final implant size prediction achieved by preoperative digital templating for TKA.

Methods

A total of 191 radiographs of patients undergoing TKA were allocated into four groups according to their KR as measured at the posterior femoral condyles and their KA as measured at the distal femoral condyles on lateral knee radiographs: group A (KR ≤ 5 mm, KA ≤ 5 mm), B1 (KR > 5 mm, KA ≤ 5 mm), B2 (KR ≤ 5 mm, KA > 5 mm) and B3 (KR > 5 mm, KA > 5 mm). Preoperative templating of femoral and tibial implant size using digital templating software was carried out by two observers. Correlation coefficients (CCs) between planned and final implant size, percentage of cases with planned to final size match as well as percentage of cases within ±1 and ±2 of planned to final size were reported according to groups.

Results

Group A showed the highest percentage of cases with matching planned to final femoral implant size (45%) and the highest percentage of cases with ±1 planned to final implant size (86%) as compared to B1 (match 28%, ±1 84%), B2 (match 41%, ±1 84%) and B3 (match 35%, ±1 78%). CCs for planned to final implant size were reported at >0.75 in all groups. No statistically significant difference in the CCs of planned to final implant size amongst groups was found.

Conclusion

The accuracy of implant size prediction achieved by preoperative digital templating for TKA is neither affected by KR nor KA on lateral knee radiographs.

Level of evidence

Level III.

Using Preference Cards to Support a Thoughtful, Evidence-based Orthopaedic Surgery Practice

INTRODUCTION

When orthopaedic surgeons begin or relocate their careers, they must communicate effectively about their instrumentation and equipment needs. 'Preference Cards' or 'Pick Lists' are generated by and for individual surgeons at the time of hire and can be updated over time to reflect their needs for common cases. Currently, such decisions are made without formal guidance or preparation.

BODY

Surgeons must consider and plan for their operating room needs. Health system and industry factors affect these decisions, as do surgeons' unique interests, preferences, and biases. Orthopaedic surgeons currently face challenges: formal education is deficient in this space, material and reprocessing costs are not transparent, relationships and contracts with industry are complex, and few health systems have mechanisms to support preference card optimization. This complex landscape influences utilization decisions and leaves opportunities for integration, collaboration, and innovation.

SUMMARY

Choices about instrument and resource utilization in the OR have wide-reaching impacts on costs, waste generation, OR efficiency, sterile processing, and industry trends. Surgeons and their teams have much to gain by making intentional choices and pursuing both individual and systematic improvements in this space.

The carbon footprint and wastage of intravitreal injections

PURPOSE

The healthcare system emits greenhouse gas emissions and produces waste that in turn threatens the health of populations. The objective of our study was to measure the ecological threat related to intravitreal injections.

METHODS

Emissions were separated into scope 2 corresponding to Heating, Ventilation and Air Conditioning (HVAC) of the building, and scope 3 corresponding to travels (patients and staff), and life cycle assessment (LCA) of medical devices (MD) and pharmaceutics. Greenhouse gas (GHG) emissions and waste for a single injection were first measured through a waste audit, and secondly anticipated theoretically with a calculator.

RESULTS

The average GHG emissions and waste measured were 277kgCO2eq/IVI and 0.5kg/IVI, respectively. Pharmaceuticals were responsible for 97% of total emissions. Emissions unrelated to pharmaceuticals counted for 8.4kgCO2eq/IVI. GHG emissions and waste estimated with the calculator were 276kgCO2eq/IVI and 0.5kg/IVI, respectively, showing that the calculator was accurate.

CONCLUSION

Our study provides a puzzle piece to carbon footprint and waste assessment in the field of ophthalmology. It may help provide concrete data for future green vs. vision discussions.

Strategies for efficient management of microplastics to achieve life cycle assessment and circular economy

The anticipated increase in the influx of plastic waste into aquatic environments has propelled the identification and elimination of plastic waste into the global agenda. The plastics sector generates a significant volume of materials, which, due to their extended durability, accumulate rapidly in natural ecosystems. Consequently, this indiscriminate utilization, along with the deposition of plastic waste (PW) in landfills and inadequate recycling practices, leads to diverse economic, social, and environmental consequences. Microplastics (MPs) are a type of PW that has been fragmented into particles measuring less than 5 mm. These particles have been found in several environments, including the air, soil, freshwater, and ocean ecosystems, where they accumulate in large quantities. In order to gain insight into the ecological risks and resource implications associated with a plastic product, it is strongly advised to conduct life cycle and sustainability analyses. Therefore, this paper examines various strategies aimed at achieving effective management of MP waste in order to develop a conceptual framework for MPs in circular economy and life cycle assessment (LCA). The findings of this study provides a new avenue for future research and contribution to manage MP waste as well as reduce their environmentally hazardous impact.

Ecological Burden of Modern Surgery: An Analysis of Total Knee Replacement's Life Cycle

Background

It is estimated that surgical procedures account for 20%-30% of the greenhouse gases emissions from health-care systems. Total knee replacements (TKR) are one of the most frequently performed procedures in orthopaedics. The aim of this study was to identify and quantify the environmental impacts generated by TKRs, the factors that generate the most emissions, and those that can be easily modified.

Methods

To calculate the life cycle carbon footprint of a posterior stabilized cemented TKR performed in a single orthopaedic surgery department, 17 TKRs performed between October 12 and 20, 2020 by 4 senior surgeons were analysed. The analysis of the life cycle included the manufacture of the implant, from raw materials to distribution; the journey made by patients and staff; and the surgery including all consumables required to facilitate the procedure.

Results

The overall life cycle carbon footprint of a single TKR was 190.5 kg of CO2. This consisted of 53.7 kg CO2 (28%) for the manufacture of the prosthesis, 50.9 kg CO2 (27%) for travel, 57.1 kg CO2 (30%) for surgery, and 28.8 kg CO2 (15%) for waste management. This is comparable to a New York-Detroit direct flight.

Conclusions

The production of a total knee prosthesis, throughout its life cycle, generates emissions with important consequences on the environment and therefore on our health. Although much data are currently missing to make precise estimates, and especially regarding benefits in terms of patient function and its impact on carbon emissions, these data serve as a starting point for other more detailed or comparative studies.

[Survey and reduction of waste production from eye surgery]

BACKGROUND

The health sector is facing new challenges due to the impact of climate change on health. At the same time, it significantly contributes to our society's climate footprint. Hospitals producing considerable amounts of waste are an important aspect of this burden. The aim of this work was to quantify the amount of waste produced by eye surgery and, as an optimization measure, to evaluate the effect of glass separation from residual waste.

MATERIAL AND METHODS

Over a 2-week period, the waste generated by eye operations in the surgical theater of our university hospital was measured. Another 2‑week long measurement was conducted after the initiation of glass separation from general waste. The data obtained allowed a comparison of the two periods, the type of waste (residual and recyclable) as well as the type of operation (intraocular, extraocular). Considering regional waste disposal costs, an economic comparison was also performed.

RESULTS

In the first measurement period (196 operations), a total of 549.6 kg of waste was generated, 87% (478.3 kg) of which was residual waste, corresponding to 14.3 tons of total waste annually. Intraocular procedures generated on average 80% more waste than extraocular procedures: 18.1 ± 3.9 kg and 11.4 ± 4.0 kg, respectively, per day and theater. Separation of glass from residual waste reduced its quantity by 7.2% in the second measurement period (197 procedures). As the disposal of glass is free of charge in the city of Essen, this resulted in a small economic advantage (extrapolated to 112 € per year).

CONCLUSION

The amount of waste generated by ophthalmic surgery is substantial, with a predominant proportion of non-recyclable residual waste. Intraocular operations are the cause of the majority of the waste produced. Simple measures, such as disposing of glass separately, are helpful and inexpensive to reduce the quantity of residual waste.

Environmental effects of surgical procedures and strategies for sustainable surgery

There is a bidirectional relationship between climate change and health care. Climate change threatens public health, and health care contributes to climate change. For example, surgery is the most energy-intensive practice in the health-care sector, and gastrointestinal conditions are responsible for a substantial environmental burden. However, environmental costs associated with health care are often overlooked. This issue has been examined more closely in current times. Emerging data are mainly focused on surgery, as the most resource-intensive practice. However, there is still a lack of global awareness and guidance on sustainable surgical practices. This Perspective aims to reassess the evidence on health care and surgery carbon footprints, focusing on gastrointestinal conditions, identify issues that need to be addressed to achieve a more sustainable practice and develop perspectives for future surgical procedures. The proposed framework to mitigate the environmental effects of surgery could be translated to other health-care sectors.

Adapting lean methodology towards surgical tray rationalisation in inguinoscrotal day case surgery in the republic of Ireland

INTRODUCTION

Lean methodologies have been used successfully in both industry and healthcare to reduce waste. The operating room (OR) and central supplies department (CSD) are areas associated with high hospital costs. The aim of this study was to employ Lean methodologies to support the rationalisation of surgical trays in paediatric inguinoscrotal surgery in order to reduce instrument wastage, processing times and overall costs in a European setting.

METHODS

This was a prospective, pilot observation and implementation study using Lean methodology including DMAIC (Define, Measure, Analyse, Improve and Control) cycles. Relevant tray set-up included trays for boys ≥12 months age undergoing open elective inguinoscrotal surgery. A comparative analysis of two phases, pre and post-standardization was then carried out with respect to operating times, instrument set-up times, tray weights, and costs. Instruments that were used <40% of the time were eliminated from the surgical tray.

RESULTS

Rationalization of the inguinoscrotal tray led to a 34.7% reduction in tray size, with a concomitant time-reduction of >2 min per case. The average overall instrument utilisation rate increased from 56% to 80% across users. Cost savings were projected at €5380.40 per annum based on current changes. There were no differences in operative time, or adverse outcomes.

DISCUSSION

At the hospital level, the reduction in variation, and rationalisation of this single surgical tray could lead to both operational (Tray assembly process; Operating rooms; Ergonomic functionality) as well as economic (Sterilisation; Instrument repair; Purchases) financial and ergonomic improvements for the healthcare system. The reduction in time taken to count and sterilise instruments can lead to a potential manpower saving involving a redistribution of activities to other areas which may require them.

CONCLUSION

Surgical tray rationalisation is emerging Lean concept with overlap across a number of specialities, and represents a technique by which to manage costs, and improve supply chain efficiency without any adverse effect in patient healthcare outcomes.

Sustainability in interventional radiology: are we doing enough to save the environment?

Background

Healthcare waste contributes substantially to the world’s carbon footprint. Our aims are to review the current knowledge of Interventional Radiology (IR) waste generation and ways of reducing waste in practice, to quantify the environmental and financial impact of waste generated and address green initiatives to improve IR waste management.

Methods

A systematic literature search was conducted in July 2022 using the Medline and Embase literature databases. The scope of the search included the field of IR as well as operating theatre literature, where relevant to IR practice.

Results

One-hundred articles were reviewed and 68 studies met the inclusion criteria. Greening initiatives include reducing, reusing and recycling waste, as well as strict waste segregation. Interventional radiologists can engage with suppliers to reformulate procedure packs to minimize unnecessary items and packaging. Opened but unused equipment can be prevented if there is better communication within the team and increased staff awareness of wasted equipment cost. Incentives to use soon-to-expire equipment can be offered. Power consumption can be reduced by powering down operating room lights and workstations when not in use, changing to Light Emitting Diode (LED) and motion sensor lightings. Surgical hand wash can be replaced with alcohol-based hand rubs to reduce water usage. Common barriers to improving waste management include the lack of leadership, misconceptions regarding infectious risk, lack of data, concerns about increased workload, negative staff attitudes and resistance to change. Education remains a top priority to engage all staff in sustainable healthcare practices.

Conclusion

Interventional radiologists have a crucial role to play in improving healthcare sustainability. By implementing small, iterative changes to our practice, financial savings, greater efficiency and improved environmental sustainability can be achieved.

Addressing Surgical Instrument Oversupply: A Focused Literature Review and Case-Study in Orthopedic Hand Surgery

BACKGROUND

Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods.

METHODS

Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research.

RESULTS

After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis.

CONCLUSIONS

Instrument oversupply drives cost at our institution's ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

Breast Surgery Cost Savings Through Surgical Tray Instrument Reduction

INTRODUCTION

Removing unnecessary instruments from surgical trays used in the operating room conserves resources and time. We aimed to assess the cost savings impact of breast surgical tray instrument reduction.

METHODS

Breast surgeons at a single institution reviewed the standard surgical tray used for lumpectomies and mastectomies and removed underutilized instruments to create a breast-specific tray. This tray was used for all breast surgeries performed throughout the 2019 calendar year. Data for breast-specific tray usage, instrument reprocessing costs, and instrument maintenance costs for inspection, sharpening, aligning, and lubricating were retrospectively obtained.

RESULTS

The breast-specific tray was reduced from 82 to 65 instruments. The cost of reprocessing each instrument is $1.69. After 30 tray sterilizations, each tray was sent for maintenance at a cost of $2.00 per instrument. With 10 breast-specific trays in circulation, the trays were used a total of 656 times during the calendar year. Each tray was sent for maintenance an average of two times during this time period. Thus, instrument reduction resulted in $18,847 in instrument reprocessing and $680.00 in maintenance savings, with total annual cost savings of $19,527.

CONCLUSIONS

Optimizing surgical trays by removing unused instruments yields significant cost savings and contributes to improved efficiency in the sterile processing department. As efforts to eliminate wasteful practices and reduce costs within the health care system continue, opportunities remain for standardization of trays across all surgical departments and institutions.

Healthcare waste generation in hospitals per continent: a systematic review

There are increasing worldwide concerns about the negative impacts of healthcare waste generated in hospitals, especially in low- and middle-income countries. Hazardous type of waste can contribute to adverse effects both in human populations and the environment because of its physical, chemical, and biological characteristics. A comprehensive view on increasing waste in the world has not been conducted to understand the breadth of the issue; thus, this paper sought to provide an analysis of hospitals' healthcare waste generation rate. Comparisons were made with Wilcoxon and Kruskal-Wallis tests for simple and multiple comparisons, to analyze nonparametric data, with post hoc by Nemenyi test. Median values indicated that hospital waste was the highest in North and South America (4.42, 1.64 kg/bed/day, respectively) and was almost nonexistent in Oceania (0.19 kg/bed/day), while the median rates for hazardous waste were the highest in Oceania (0.77 kg/bed/day). Africa was almost the lowest producer of waste in each category (0.19 and 0.39 kg/bed/day for hospital and hazardous waste, respectively). Over time, linear regression indicated that hazardous waste in Asia and Europe has increased, while in Oceania, the total waste also increased. Interestingly, in North America, it was observed a reduction in the generation for both total and hazardous waste. This information highlights the importance of understanding continent-specific characteristics and rates, which can be used to create a more individualized approach to addressing healthcare waste in the world.

Minimising carbon and financial costs of steam sterilisation and packaging of reusable surgical instruments

BACKGROUND

The aim of this study was to estimate the carbon footprint and financial cost of decontaminating (steam sterilization) and packaging reusable surgical instruments, indicating how that burden might be reduced, enabling surgeons to drive action towards net-zero-carbon surgery.

METHODS

Carbon footprints were estimated using activity data and prospective machine-loading audit data at a typical UK in-hospital sterilization unit, with instruments wrapped individually in flexible pouches, or prepared as sets housed in single-use tray wraps or reusable rigid containers. Modelling was used to determine the impact of alternative machine loading, opening instruments during the operation, streamlining sets, use of alternative energy sources for decontamination, and alternative waste streams.

RESULTS

The carbon footprint of decontaminating and packaging instruments was lowest when instruments were part of sets (66-77 g CO2e per instrument), with a two- to three-fold increase when instruments were wrapped individually (189 g CO2e per instrument). Where 10 or fewer instruments were required for the operation, obtaining individually wrapped items was preferable to opening another set. The carbon footprint was determined significantly by machine loading and the number of instruments per machine slot. Carbon and financial costs increased with streamlining sets. High-temperature incineration of waste increased the carbon footprint of single-use packaging by 33-55 per cent, whereas recycling reduced this by 6-10 per cent. The absolute carbon footprint was dependent on the energy source used, but this did not alter the optimal processes to minimize that footprint.

CONCLUSION

Carbon and financial savings can be made by preparing instruments as part of sets, integrating individually wrapped instruments into sets rather than streamlining them, efficient machine loading, and using low-carbon energy sources alongside recycling.

A Standardized Method for Estimating the Carbon Footprint of Disposable Minimally Invasive Surgical Devices: Application in Transurethral Prostate Surgery

Objective

To propose a standardized methodology for estimating the embodied carbon footprint (CF) of disposable minimally-invasive surgical devices (MISDs) and their application in new benign prostatic hyperplasia (BPH) MISDs.

Summary of Background Data

The estimation of the CO2e emissions of disposable surgical devices is central to empowering the healthcare supply chain.

Methods

The proposed methodology relied on a partial product lifecycle assessment and was restricted to a specific part of scope 3, which comprised the manufacturing of surgical device- and non-device-associated products (NDAPs), including packaging and user manual. The process-sum inventory method was used, which involves collecting data on all the component processes underpinning disposable MISDs. The seven latest disposable MISDs used worldwide for transurethral prostatic surgery were dismantled, and each piece was categorized, sorted into the appropriate raw material group, and weighed. The CF was estimated according to the following formula: activity data (weight of raw material) × emission factors of the corresponding raw material (kg CO2e/kg).

Results

The total weights of disposable packaging and user manuals ranged from 0.062 to 1.013 kg. Plastic was the most common and least emissive raw material (2.38 kg CO2e/kg) identified. The estimated embodied CF of MISDs ranged from 0.07 to 3.3 kg CO2e, of which 9% to 86% was attributed to NDAPs.

Conclusions

This study described a simple and independent calculation method for estimating the embodied CF of MISDs. Using this method, our results showed a wide discrepancy in the estimated CO2 emissions of the most recent disposable MISDs for transurethral BPH surgery. Thus, the lack of CF information should be of major concern in the development of future MISDs.

The design and evaluation of a novel algorithm for automated preference card optimization

BACKGROUND

Inaccurate surgical preference cards (supply lists) are associated with higher direct costs, waste, and delays. Numerous preference card improvement projects have relied on institution-specific, manual approaches of limited reproducibility. We developed and tested an algorithm to facilitate the first automated, informatics-based, fully reproducible approach.

METHODS

The algorithm cross-references the supplies used in each procedure and listed on each preference card and uses a time-series regression to estimate the likelihood that each quantity listed on the preference card is inaccurate. Algorithm performance was evaluated by measuring changes in direct costs between preference cards revised with the algorithm and preference cards that were not revised or revised without use of the algorithm. Results were evaluated with a difference-in-differences (DID) multivariate fixed-effects model of costs during an 8-month pre-intervention and a 15-month post-intervention period.

RESULTS

The accuracies of the quantities of 469 155 surgeon-procedure-specific items were estimated. Nurses used these estimates to revise 309 preference cards across eight surgical services corresponding to, respectively, 1777 and 3106 procedures in the pre- and post-intervention periods. The average direct cost of supplies per case decreased by 8.38% ($352, SD $6622) for the intervention group and increased by 13.21% ($405, SD $14 706) for the control group (P < .001). The DID analysis showed significant cost reductions only in the intervention group during the intervention period (P < .001).

CONCLUSION

The optimization of preference cards with a variety of institution-specific, manually intensive approaches has led to cost savings. The automated algorithm presented here produced similar results that may be more readily reproducible.

Nurses´ and nurse managers´ perceptions of sustainable development in perioperative work: A qualitative study

AIMS AND OBJECTIVES

To describe how nurses and nurse managers consider sustainable development principles in their daily work, how well they recognise these principles and how these principles are considered in decision-making in perioperative work.

BACKGROUND

Sustainable development involves interpersonal social and cultural relations and long-term economic and ecological thinking in societal decision-making. These dimensions are well-suited for a foundation of decision-making in acute health care. No previous research has been performed on perioperative work from the sustainable development perspective.

DESIGN

Qualitative descriptive design was used. Data were collected from perioperative nurses (n = 20) and nurse managers (n = 6) working in five surgical departments in a Finnish university hospital. Data were analysed by content analysis. The reporting follows qualitative research checklist (COREQ).

RESULTS

The principles of sustainable development were poorly known among the participants. Nurse managers considered their opportunities to influence decision-making were reduced by their limited economic knowledge. Resource use, individuality, and ecological viewpoints were emphasised in the decision-making process in perioperative work.

CONCLUSIONS

Findings reveal that perioperative nurses and nurse managers are aware of economic and ecological sustainability, but they do not actively consider it as part of their work. Social and cultural sustainability must be developed further in decision-making in perioperative work.

RELEVANCE TO CLINICAL PRACTICE

Perioperative nurses and nurse managers consider that it is important to develop the principles of sustainable development in perioperative work. This research indicates that economic understanding is not guiding decision-making, and there is a lack of knowledge about the benefits of ecological procedures. Social and cultural sustainability are not connected in perioperative work, although there is collaboration between the surgical team and the patient is essential. This study helps to organise operating room management effectively and diversely.

Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains

PURPOSE

Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense.

METHODS

A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process.

RESULTS

A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually.

CONCLUSIONS

An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.

Radiofrequency Identification Track for Tray Optimization: An Instrument Utilization Pilot Study in Surgical Oncology

BACKGROUND

Surgical instrument tray reduction attempts to minimize intraoperative inefficiency and processing costs. Previous reduction methods relied on trained observers manually recording instrument use (i.e. human ethnography), and surgeon and/or staff recall, which are imprecise and inherently limited. We aimed to determine the feasibility of radiofrequency identification (RFID)-based intraoperative instrument tracking as an effective means of instrument reduction.

METHODS

Instrument trays were tagged with unique RFID tags. A RFID reader tracked instruments passing near RFID antennas during 15 breast operations performed by a single surgeon; ethnography was performed concurrently. Instruments without recorded use were eliminated, and 10 additional cases were performed utilizing the reduced tray. Logistic regression was used to estimate odds of instrument use across cases. Cohen's Kappa estimated agreement between RFID and ethnography.

RESULTS

Over 15 cases, 37 unique instruments were used (median 23 instruments/case). A mean 0.64 (median = 0, range = 0-3) new instruments were added per case; odds of instrument use did not change between cases (OR = 1.02, 95%CI 1.00-1.05). Over 15 cases, all instruments marked as used by ethnography were recorded by RFID tracking; 7 RFID-tracked instruments were never recorded by ethnography. Tray size was reduced 40%. None of the 25 eliminated instruments were required in 10 subsequent cases. Cohen's Kappa comparing RFID data and ethnography over all cases was 0.82 (95%CI 0.79-0.86), indicating near perfect agreement between methodologies.

CONCLUSIONS

Intraoperative RFID instrument tracking is a feasible, data-driven method for surgical tray reduction. Overall, RFID tracking represents a scalable, systematic, and efficient method of optimizing instrument supply across procedures.

Approaches to the rationalization of surgical instrument trays: scoping review and research agenda

BACKGROUND

Surgical Tray Rationalization (STR) consists of a systematic reduction in the number of surgical instruments to perform specific procedures without compromising patient safety while reducing losses in the sterilization and assembly of trays. STR is one example of initiatives to improve process performance that have been widely reported in industrial settings but only recently have gained popularity in healthcare organizations.

METHODS

We conduct a scoping review of the literature to identify and map available evidence on surgical tray management. Five methodological stages are implemented and reported; they are: identifying research questions, identifying relevant studies, study selection, charting the data, and collating, summarizing and reporting the results.

RESULTS

We reviewed forty-eight articles on STR, which were grouped according to their main proposed approaches: expert analysis, lean practices, and mathematical programming. We identify the most frequently used techniques within each approach and point to their potential contributions to operational and economic dimensions of STR. We also consolidate our findings, proposing a roadmap to STR with four generic steps (prepare, rationalize, implement, and consolidate) and recommended associated techniques.

CONCLUSIONS

To the best of our knowledge, ours is the first study that reviews and systematizes the existing literature on the subject of STR. Our study closes with the proposition of future research directions, which are presented as nine research questions associated with the four generic steps proposed in the STR roadmap.

Data analysis of vascular surgery instrument trays yielded large cost and efficiency savings

BACKGROUND

Surgical procedures account for 50% of hospital revenue and ∼60% of operating costs. On average, <20% of surgical instruments will be used during a case, and the expense for resterilization and assembly of instrument trays ranges from $0.51 to $3.01 per instrument. Given the complexity of the surgical service supply chain, physician preferences, and variation of procedures, a reduction of surgical cost has been extremely difficult and often ill-defined. A data-driven approach to instrument tray optimization has implications for efficiency and cost savings in sterile processing, including reductions in tray assembly time and instrument repurchase, repair, and avoidable depreciation.

METHODS

During a 3-month period, vascular surgery cases were monitored using a cloud-based technology product (OpFlow, Operative Flow Technologies, Raleigh, NC) as a part of a hospital-wide project. Given the diversity of the cases evaluated, we focused on two main vascular surgery trays: vascular and aortic. An assessment was performed to evaluate the exact instruments used by the operating surgeons across a variety of cases. The vascular tray contained 131 instruments and was used for the vast majority of vascular cases, and the aortic tray contained 152 instruments. Actual instrument usage data were collected, a review and analysis performed, and the trays optimized.

RESULTS

During the 3-month period, 168 vascular surgery cases were evaluated across six surgeons. On average, the instrument usage per tray was 30 of 131 instruments (22.9%) for the vascular tray and 19 of 152 (12.5%) for the aortic tray. After review, 45.8% of the instruments were removed from the vascular tray and 62.5% from the aortic tray, for 1255 instruments removed from the versions of both trays. An audit was performed after the removal of instruments, which showed that none of the removed instruments had required reinstatement. The instrument reduction from these two trays alone yielded an estimated costs savings of $97,781 for repurchase and $97,444 in annual resterilization savings. Annually, the removal of the instruments is projected to save 316.2 hours of personnel time. The time required for operating room table setup decreased from a mean of 7:44 to 5:02 minutes for the vascular tray (P < .0001) and from 8:53 to 4:56 minutes for the aortic tray (P < .0001).

CONCLUSIONS

Given increasing cost constraints in healthcare, sterile processing remains an untapped resource for surgical expense reduction. A comprehensive data analytics solution provided the ability to make informed decisions in tray management that otherwise could not be reliably performed.

Considerations for environmentally sustainable head and neck surgical oncology practice

OBJECTIVE

To evaluate the potential role of head and neck oncologic surgeons in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future.

REVIEW METHODS

This literature review searched for relevant literature about the relevance of waste in surgical head and neck oncology practice and the innovative alternatives to decrease its effect on environment.

CONCLUSIONS

Head and neck oncologic surgeons have a role in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future. However, there exist only limited data on waste management and other procedures in surgical oncology to promote these practices.

IMPLICATIONS FOR PRACTICE

By increasing awareness of the corresponding issues of waste production within the healthcare environment, head and neck surgeons can have a pioneering role in considering how to reduce, recycle and reuse in a more efficient manner. As research in this field accumulates, healthcare providers can engage both managers and clinicians in this process. It remains imperative to provide these professionals opportunities for their work force to rethink current practices in a manner that prioritizes environmentally sustainable head and neck surgical practices.

Health economic evaluation of a clinical pharmacist's intervention on the appropriate use of devices and cost savings: A pilot study

BACKGROUND

Good management of disposable and reusable supplies may improve surgical efficiency in the operating room (OR) and also corresponds to the best eco-responsible approach. The purpose of this study was to assess the impact of a clinical pharmacist's intervention in the OR on the non-compliant use of medical devices. We also assessed the economic impact of the pharmaceutical intervention.

MATERIALS AND METHODS

We conducted a monocentric prospective study in the OR of a University hospital over one year. Three surgical specialties: urologic, digestive and gynecologic were audited after a preparatory phase to optimize usage of medical devices used for surgeries. The supply costs concerning the three specialties were compared before and after the pharmacist intervention.

RESULTS

One hundred and fifty surgical procedures were audited in digestive (33.3%, n = 50), gynecologic (32%, n = 48) and urologic (34.7%, n = 52) surgeries. With the pharmacist in OR, 51 procedures (34% CI95%[26.4%; 41.6%]) with a non-compliance concerning at least one medical device were found compared to the 50% rate without the pharmacist reported previously (P < .0001). Eighteen percent of surgical procedures had at least one circulator retrieval for the reason "incomplete case cart despite device listed on the case cart list" versus 29.1% before pharmacist intervention (P = .0028). A €33 014 saving associated with the presence of the pharmacist in OR was observed.

CONCLUSIONS

This prospective interventional study showed that the intervention of a pharmacist specialized in the medical device field could significantly reduce non-compliances in medical device use and reduce costs in OR.

Waste production from phacoemulsification surgery

PURPOSE

To determine the amount of waste produced from phacoemulsification surgeries and ways to curtail the problem.

SETTING

Miri Hospital, Sarawak, Malaysia.

DESIGN

Prospective study.

METHODS

Phacoemulsification surgery cases were included in this study; nonphacoemulsification surgeries were excluded. The waste was subdivided into 3 main categories, general waste, clinical waste, and sharps. The waste produced by ophthalmologists and trainees was accounted for separately. The mean weight of waste per case was obtained by dividing the total weight of waste produced with the total number of cases.

RESULTS

The total waste produced from a total of 203 cases of phacoemulsification surgeries was 167.965 kg, of which, 95.063 kg (56.6%) were clinical waste, 63.197 kg (37.6%) were general waste, and 9.705 kg (5.8%) were sharps; 32.193 kg (50.9%) out of the general waste pool were recyclable waste products. The mean waste production per case of phacoemulsification surgery for an ophthalmologist was 0.814 kg, 1.086 kg per case for a trainee. A case of phacoemulsification surgery would produce 0.282 kg of carbon dioxide equivalents in the setup based on the recyclable general waste.

CONCLUSIONS

The average waste produced per case of phacoemulsification surgery in Miri Hospital was 0.827 kg. After excluding the recyclable material, the average waste produced per case was 0.669 kg. Following the 3 R's principles (reduce, reuse, and recycle) in the handling of waste production might reduce environmental impact.

Direct Cost Comparison of Open Carpal Tunnel Release in Different Venues

Background: The increased efficiency and cost savings have led many surgeons to move their practice away from the traditional operating room (OR) or outpatient surgery center (OSC) and into the clinic setting. With the cost of health care continuing to rise, the venue with the lowest cost should be utilized. We performed a direct cost analysis of a single surgeon performing an open carpal tunnel release in the OR, OSC, and clinic. Methods: Four treatment groups were prospectively studied: the hospital OR with monitored anesthesia care (OR-MAC), OSC with MAC (OSC-MAC), OSC with local anesthesia (OSC-local), and clinic with local anesthesia (clinic). To determine direct costs, a detailed inventory was recorded including the weight and disposal of medical waste. Indirect costs were not included. Results: Five cases in each treatment group were prospectively recorded. Average direct costs were OR ($213.75), OSC-MAC ($102.79), OSC-local ($55.66), and clinic ($31.71). The average weight of surgical waste, in descending order, was the OR (4.78 kg), OSC-MAC (2.78 kg), OSC-local (2.6 kg), and the clinic (0.65 kg). Using analysis of variance, the clinic's direct costs and surgical waste were significantly less than any other setting (P < .005). Conclusions: The direct costs of an open carpal tunnel release were nearly 2 times more expensive in the OSC compared with the clinic and almost 7 times more expensive in the OR. Open carpal tunnel release is more cost-effective and generates less medical waste when performed in the clinic versus all other surgical venues.

Environmental sustainability in veterinary anaesthesia

OBJECTIVE

Attention is drawn to the potential of global warming to influence the health and wellbeing of the human race. There is increasing public and governmental pressure on healthcare organisations to mitigate and adapt to the climate changes that are occurring. The science of anaesthetic agents such as nitrous oxide and the halogenated anaesthetic agents such as greenhouse gases and ozone-depleting agents is discussed and quantified. Additional environmental impacts of healthcare systems are explored. The role of noninhalational anaesthetic pharmaceuticals is discussed, including the environmental life-cycle analyses of their manufacture, transport, disposal and use. The significant role of anaesthetists in recycling and waste management, resource use (particularly plastics, water and energy) and engagement in sustainability are discussed. Finally, future directions for sustainability in veterinary anaesthesia are proposed.

CONCLUSIONS

Veterinary anaesthetists have a considerable opportunity to drive sustainability within their organisations through modification of their practice, research and education. The principles of sustainability may help veterinary anaesthetists to mitigate and adapt to our environmental crisis. Due to their particular impact as greenhouse gases, anaesthetic agents should be used conservatively with the lowest safe fresh gas flow possible. Technologies for reprocessing anaesthetic agents are described.

Environment-Friendly Practices in Operating Rooms in Turkey

BACKGROUND

Environment-friendly practices refer to decreasing energy consumption, using resources carefully and sustainably, and reducing environmental pollution. An environment-friendly hospital is defined as a hospital where energy is saved, carbon emissions are decreased, and productivity and quality are increased. Operating rooms (ORs) account for most wastes generated daily by hospitals. Thus, adopting environment-friendly healthcare practices in ORs will have a positive impact on the environment.

PURPOSE

The aim of this study was to identify and recommend environment-friendly practices that are feasible for implementation in ORs in Turkey.

METHODS

Data on the environment-friendly practices that are currently being practiced in the ORs of hospitals in Izmir Province were collected using face-to-face interviews with nurses who were in charge of ORs in Izmir Province. The interviews were conducted using an OR identification form and Greening the OR Checklist. The study population included all of the hospitals in Izmir Province, and the study sample included 18 ORs in the 11 hospitals that consented to take part in the research. Permission to conduct this research was obtained from the ethics committee of the nursing school as well as from the participating hospitals where the study was conducted.

RESULTS

The hospitals included in the study had, on average, 7.44 ± 7.32 ORs, each of which employed an average of 16.83 ± 17.16 nurses. Four fifths (83.3%) of the ORs always monitored their wastes, and 88.9% gave their batteries to recyclers. In addition, 72.2% renewed their surgical sets to reduce excessive use of materials, and 72.2% preferred using reusable materials instead of single-use materials in their surgical sets. However, 66.7% of the ORs had no environmental team, 93% did not use an environmentally safe surface cleaner, 83.3% did not use sensor controls on lights, and 66.7% did not use LED lights.

CONCLUSIONS

Although most hospitals did not have a special team to recommend and enforce environment-friendly procedures, the OR nurses did their best to protect the environment.

Inventory management of surgical supplies and sterile instruments in hospitals: a literature review

Operating rooms are considered a significant revenue source, as well as the main source of waste and cost, among the hospital's departments. Any cost savings in operating rooms will have a broad financial impact. Over the last decades, many researchers and practitioners have conducted studies to deal with the issue of managing surgical supplies and instruments, which are highly affected by surgeons' preferences. The purpose of this article is to present an up-to-date review of research in the field of inventory management of surgical supplies and instruments. We have analysed the literature in a systematic manner and organised the identified papers into two groups: the papers that were published by scientific researchers and developed optimisation techniques and the papers that were published by practitioners and reported their observations of the current issues in the operating room. We also identify the future research directions leading to operating room inventory cost reduction.