he 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become out of date.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.