Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review

BACKGROUND

Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs.

STUDY DESIGN

A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework.

RESULTS

A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste).

CONCLUSIONS

Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.

Comparison of new versus reused Harmonic scalpel performance in laparoscopic appendectomy in patients with acute appendicitis-a randomized clinical trial

BACKGROUND

The aim of this study was to compare lateral thermal damage of the appendix and clinical outcomes after laparoscopic appendectomy using new versus reused Harmonic scalpels.

METHODS

A total of 100 consecutive patients with acute appendicitis who underwent laparoscopic appendectomy were enrolled in the two-center, randomized clinical trial. Using a computer random number generator, patients were allocated to new or reused group. Histopathological measurement of lateral thermal damage of the appendiceal base and mesoappendix, speed of transection of the appendiceal base, duration of surgery, subjective rating of device functionality, length of hospital stay, and complications were compared within groups.

RESULTS

The median lateral thermal damage on the appendiceal base in the new group (N = 49) was 0.2 mm (IQR 0.1-0.2) and 0.1 mm (IQR 0.1-0.3) in the reused group (N = 51) (P = 0.644), while on the mesoappendix for both groups, thermal damage was 0.1 mm (IQR 0.1-0.2) (P = 0.418). The median time required for base transection in both groups was 8 s (IQR 7-9) (P = 0.776). The median duration of surgery was also comparable between the groups (22 min, IQR 20-30 vs 25 min, IQR 21-35; P = 0.233). Two postoperative complications in the new group and one in the reused group were recorded (4% vs 2%; P = 0.536). Surgeons' subjective assessment of the instrument did not reveal significant difference between the groups in all of the investigated categories.

CONCLUSIONS

The results of our study support the reuse of Harmonic scalpels especially in the settings where economic constraints might hamper access to minimally invasive surgery to a larger number of patients. The results obtained on laparoscopic appendectomy might not be reproducible to other more demanding surgical procedures.

TRIAL REGISTRATION

ClinicalTrials.gov registry under identifier NCT04226482.

Cost analysis of laparoscopic appendectomy in a large integrated healthcare system

INTRODUCTION

Healthcare expenditure is on the rise placing greater emphasis on operational excellence, cost containment, and high quality of care. Significant variation is seen in operating room (OR) costs with common surgical procedures such as laparoscopic appendectomy. Surgeons can influence cost through the selection of instrumentation for common surgical procedures such as laparoscopic appendectomy. We aimed to quantify the cost of laparoscopic appendectomy in our healthcare system and compare cost variations to operative times and outcomes.

METHODS AND PROCEDURES

We performed a retrospective review of laparoscopic appendectomies in a large regional healthcare system during one-year period (2018). Operating room supply costs and procedure durations were obtained for each hospital. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) outcomes and demographics were compared to the costs for each hospital.

RESULTS

A total of 4757 laparoscopic appendectomies were performed at 20 hospitals (27 to 522 per hospital) by 233 surgeons. The average supply cost per case ranged from $650 to $1067. Individual surgeon cost ranged from $197 to $1181. The average operative time was 41 min (range 33 to 60 min). There was no association between lower cost and longer operative time. The patient demographics and comorbidities were similar between sites. There were no significant differences in postoperative complications between high- and low-cost centers. The items with the greatest increase in cost were single-use energy devices (SUD) and endoscopic stapler. We estimate that a saving of over $417 per case is possible by avoiding the use of energy devices and may be as high as $ 984 by adding selective use of staplers. These modifications would result in an annual savings of $1 million for our health system and more than $ 125 million nationwide.

CONCLUSION

Performing laparoscopic appendectomy with reusable instruments and finding alternatives to expensive energy devices and staplers can significantly decrease costs and does not increase operative time or postoperative complications.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Exposure to reprocessed single-use tracheal suction catheter and ventilator-associated pneumonia risk: A preliminary, single unit-based, matched case-control study

PURPOSE

The reuse of reprocessed single-use suction catheter for suctioning an amount of tracheal secretion among orally intubated, mechanically ventilated patients, who are at risk of acquiring ventilator-associated pneumonia (VAP), has not been thoroughly investigated. This study aimed to examine the association between the repetitive use of reprocessed single-use suction catheter and VAP development.

MATERIALS AND METHODS

A preliminary, single unit-based investigation was designed as matched case-control study to extract data from hospital's existing 5-year VAP report and inpatients' clinical records. Cases were defined as patients, who developed VAP between December 2009 and October 2014. Controls were defined as patients, who had no evidence of VAP during study period. Six hundred eight controls were frequency matched to 152 cases in 4:1 ratio. Chart-extracted clinical data were stratified and included for conditional logistic regression analysis.

RESULTS

Analysis showed a significant association between reprocessed single-use tracheal suction catheter exposure and VAP development [odds ratio (OR), 3.64; 95% confidence interval (CI), 2.47-5.35]. A statistically significant increase in VAP risk was found in male intubated patients (OR, 5.33; 95% CI, 1.22-23.3), who are older than 60 years (OR, 8.08; 95% CI, 1.47-44.3), had severe Glasgow Coma Scale scores (OR, 8.27; 95% CI, 1.83-37.3), and received mechanical ventilatory support for more than 96 hours (OR, 9.67; 95% CI, 1.98-47.1). In addition, a statistically significant increase in VAP risk was seen in intensive care unit, where reprocessed tracheal suction catheter changes were routinely provided (OR, 16.0; 95% CI, 2.40-106.7) and unsatisfactory hand hygiene percentage compliance was observed (OR, 8.40; 95% CI, 1.60-44.1). Ventilator-associated pneumonia proportion analysis revealed a higher number of unknown exogenous VAP among exposed cases compared to nonexposed case patients (32.2% vs 13.8%; OR, 2.31; 95% CI, 1.31-4.05; P < .005) that were mechanically ventilated for more than 96 hours (62.5% vs 25.7%; OR, 3.62; 95% CI, 2.40-5.46; P < .0001).

CONCLUSIONS

This current study suggests that exposure to reprocessed single-use tracheal suction catheter may predispose orally intubated, mechanically ventilated patients in developing VAP. Further research studies are recommended to validate these findings.

IMPLICATIONS FOR CLINICAL NURSING PRACTICE

The estimated VAP risk of this traditional-based practice is essential to provide strong basis for infection control measures to reduce, if not totally eliminate, VAP.

Reprocessed arthroscopic shavers: evaluation of sharpness and function in a cadaver model

This study was designed to test limited arthroscopic shaver reuse following reprocessing and to compare the functional performance between new and reprocessed arthroscopic shavers in arthroscopic procedures using fresh cadaveric knees. A trial using arthroscopic procedures (menisectomy, synovectomy, and debridements) was conducted by experienced surgeons using cadaveric knees to determine whether the surgeons could correctly identify reprocessed shavers. Thirty-nine shavers were tested; the surgeons were given both new and reprocessed shavers. Thirteen of the 39 shavers were new and 26 were reprocessed (13 of which had also been sharpened). The surgeons were asked to assess whether each shaver was new or reprocessed and to indicate whether the shaver was functional or not. Cadaveric shavers were subsequently used in an engineering test developed to measure shaver blade sharpness. Comparisons in sharpness were made between new and reprocessed cadaveric shaver blades. The success rate in identifying reprocessed shavers was determined to be 42% (11 of 26), with an upper confidence bound of 60%, demonstrating that the ability to detect a reprocessed shaver is no better than chance (50%), with a margin of error of 10% (P=.0328). In addition, engineering sharpness testing demonstrated that new and reprocessed cadaveric blades exhibit equivalent sharpness. Surgeons were unable to distinguish reprocessed arthroscopic shavers that passed acceptance tests from new shavers based on functional characteristics. This outcome is not unexpected due to the fact that engineering testing of shaver blades used in the study indicated that they exhibited similar sharpness.

Reuse of medical devices: implications for infection control

Reuse of both single-use and multiuse medical devices is a common practice and can result in transmission of infection when appropriate sterilization or reprocessing does not occur. Reuse of single-use devices can be problematic because there are no clear standards for reprocessing, although data regarding adverse outcomes are limited. Single-use devices are commonly reused, appropriately or inappropriately, in resource-limited settings because of cost constraints. Reuse of medical devices raises important legal and ethical questions.

Re-use of explanted osteosynthesis devices: a reliable and inexpensive reprocessing protocol

INTRODUCTION

Orthopaedic surgical treatments emphasizing immobilization using open reduction and internal fixation with osteosynthesis devices are widely accepted for their efficacy in treating complex fractures and reducing permanent musculoskeletal deformity. However, such treatments are profoundly underutilized in low- and middle-income countries (LMIC), partially due to inadequate availability of the costly osteosynthesis devices. Orthopaedic surgeons in some LMIC regularly re-use osteosynthesis devices in an effort to meet treatment demands, even though such devices typically are regulated for single-use only. The purpose of this study is to report a reprocessing protocol applied to explanted osteosynthesis devices obtained at a leading trauma care hospital.

METHODS

Explanted osteosynthesis devices were identified through a Register of Explanted Orthopaedic Prostheses. Guidelines to handle ethical issues were approved by the local Ethical Committee and informed patient consent was obtained at the time of explant surgery. Primary acceptance criteria were established and applied to osteosynthesis devices explanted between 2005 and 2008. A rigorous protocol for conducting decontamination and visual inspection based on specific screening criteria was implemented using simple equipment that is readily available in LMIC.

RESULTS

A total of 2050 osteosynthesis devices, including a large variety of plates, screws and staples, were reprocessed using the decontamination and inspection protocols. The acceptance rate was 66%. Estimated labour time and implementation time of the protocol to reprocess a typical osteosynthesis unit (1 plate and 5 screws) was 25 min, with an estimated fixed cost (in Italy) of €10 per unit for implementing the protocol, plus an additional €5 for final sterilization at the end-user hospital site.

DISCUSSION

This study was motivated by the treatment demands encountered by orthopaedic surgeons providing medical treatment in several different LMIC and their need for access to basic osteosynthesis devices. The rigorous decontamination protocol and generalized inspection criteria proved useful for efficiently screening a large volume of devices. Given that re-used osteosynthesis devices can yield satisfactory results, this study addresses potential complications of re-used devices and valid concerns that relate to patient safety. Implementing this defined reprocessing protocol into existing re-use practises in LMIC helps to limit the risks of inadequate sterilization and structural failure without adding additional risks to patients receiving re-used devices.

What is the use? An international look at reuse of single-use medical devices

Reuse of single-use devices is common in most countries worldwide. We provide an overview of the issue from an international perspective. In many developing and transitional countries reuse of cheap single-use devices (needles, syringes, surgical gloves) is common leading to large numbers of unsafe interventions, specifically injections and, as a consequence, infection with hepatitis B, C or HIV. There are various reasons for reuse: limited resources, insufficient knowledge of healthcare workers and the belief of patients that injection is more beneficial than oral medication. Reuse of cheap single-use devices should cease and both medical staff and the public should be informed about potential safety risks associated with injection. In developed countries, reuse of single-use items is less common but may include expensive technical products. Reuse is regulated in many countries (e.g. US, Canada, some European countries) demanding ethical and legal considerations, high standards of reprocessing and training of staff, risk assessment, management and validation of reprocessing. Well regulated reprocessing can decrease the number of single-use devices reprocessed. In developing as well as developed countries, a decision to reprocess single-use devices should only be made after a critical reflection of advantages and disadvantages.