INSIDE THE CURRENT ISSUE

May 2008

Back Talk

Making a case for
fully integrated case carts

To support the OR merely with case carts
is no longer enough

by David Kaczmarek, FAHRMM, CMRP

The use of case carts in the OR has been practiced for a long time. In the beginning central service began sending all the instrumentation for a case on a cart. As the value of this practice was recognized the concept was slowly expanded to include some disposables – usually bulky packs and gowns. This reduced the space needed in the operating room to store these supplies and made pulling cases faster.

Progressive organizations continued to expand the numbers and types of supplies being added to the case cart before it was transported to the OR. Now the best systems have virtually all the supplies and instruments picked outside of the OR (or inside the OR by materials specialists) and transported to the appropriate OR suite via case cart. Exceptions include items that are very hard to standardize like gloves or suture, and sized items like implants. This, in itself, is a good practice, but it is not a best practice.

Best practices in case carts will include four important elements:

• The first is automation of the pick lists. A case cart program will not be efficient unless the pick lists are computerized, updated on a regular basis and used exclusively. This also means eliminating the hard-copy five-inch-by-eight-inch preference cards. Discarding the old card is a necessary step. If you are in the process of automating, do not fall into the trap of keeping the cards "as a backup." They will quickly become out of date. Further, some staff will continue to rely on them.

• The second is standardization. Given free reign surgeons will customize the supplies and instruments they use for virtually every case. Go into most ORs and ask to see their preference card files. You will often find literally thousands of individual 5-by-8 cards, one for each type of procedure for each surgeon – each with (often slight) variations in the supplies and instrumentation. But many organizations have found it is possible to greatly standardize the most common procedures. This standardization has many benefits including better patient outcomes. It also makes for a significantly better operating case cart system.

• The third element is integration of the case cart system with the materials management information system (MMIS). Most case cart software programs include an inventory management component. The most effective case cart systems maintain a perpetual inventory of the supplies. Whether this inventory is maintained on the MMIS or the surgical system (ORIS) is not terribly important. What is important is that the two systems are integrated at some point. Regardless of where the inventory resides, case supplies should be automatically deducted from inventory when the case is pulled. If the inventory will reside in the ORIS it must be integrated at the purchasing/item master level. Pricing must be updated with each purchase, inventory must be increased with each receipt and items must automatically be put on purchase orders as they reach their reorder points.

• The final element is integration with the patient billing system. At the end of the case, all supplies pulled for the case – less any items not used and returned into inventory – should be automatically added to the patient bill. Alternately, if procedure based charging is being done, the system would input the standard procedure charge. Further, the system will track actual supply costs by procedure for easy updating of the procedure charge.

There are a variety of models for the physical picking and transportation process. At one end of the spectrum all supplies and sterilized instruments are housed in the OR core and are picked by OR staff (hopefully techs or materials specialists) or materials management staff who are assigned to the OR. At the other end of the spectrum all case cart preparation is accomplished off-site at a service center.

Central sterile staff begins the process by placing all the instrumentation on the cart. Materials staff then adds the disposable supplies and readies the carts for transportation to the appropriate location. Whether your system is the former, the latter or anything in between, will be dictated by a number of factors. They all can be efficient systems and considered best practice as long as the four elements – automated pick lists, standardization, integration with the MMIS and integration with the patient billing system – are all in place.

One final word concerns the partial outsourcing of this function. Many organizations have partially outsourced a piece of the case cart program through the use of custom sterile kits. Other organizations have taken this one step farther by using a total procedure supply bundle (with both the custom kit and other individually sterile or non-sterile supplies provided in a single container). In the right circumstances these systems can be cost effective. But frequently they are used to offset dysfunctional internal operations. Often a best practice case cart system will prove to be better both operationally and fiscally.

David Kaczmarek, FAHRMM, CMRP, is principal of Healthcare Supply Chain Solutions, Derry, NH. Kaczmarek has more that 25 years experience in healthcare administration and materials management, including director positions at several hospitals and systems. He can be reached via e-mail at mmexec@verizon.net.