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         Clinical intelligence for supply chain leadership



December 2010

Operating Room

Healthcare Purchasing News December 2010 Cover

Outpatient Connection

Hospitalizations for medication conditions on the rise among Americans ages 45 and older

The number of hospital admissions among Americans ages 45 and older for medication and drug-related conditions doubled between 1997 and 2008, according to a new report released by HHS’ Agency for Healthcare Research and Quality. Medication and drug-related conditions include effects of both prescription and over-the-counter medications as well as illicit drugs.

Hospital admissions among those 45 years and older were driven by growth in discharges for three types of medication and drug-related conditions – drug-induced delirium; "poisoning" or overdose by codeine, meperidine and other opiate-based pain medicines; and withdrawal from narcotic or non-narcotic drugs.

Admissions for all medication and drug-related conditions grew by 117% – from 30,100 to 65,400 – for 45-to 64-year-olds between 1997 and 2008. The rate of admissions for people ages 65 to 84 closely followed, growing by 96%, and for people ages 85 and older, the rate grew by 87%. By comparison, the number of hospital admissions for these conditions among adults ages 18 to 44 declined slightly by 11%.

The new AHRQ report also shows that Medicare and Medicaid were responsible for 57% of the $1.1 billion cost to hospitals in 2008 for treating patients with medication and drug-related conditions, private insurance covered 24%, and the uninsured accounted for 14%. The remaining 5% of hospital costs for treating these conditions were borne by other sources such as TRICARE.

Pneumonia is misdiagnosed on patient readmissions

Patients were misdiagnosed with pneumonia at an alarming rate when they were readmitted to the hospital shortly after a previous hospitalization for the same illness leading to overuse of antibiotics and increased healthcare costs, according to two Henry Ford Hospital companion studies. Pneumonia ranks second to congestive heart failure as the reason for readmission within 30 days of a previous hospitalization.

Researchers found that 72% of patients were misdiagnosed with pneumonia upon readmission to the same hospital; 72% of the misdiagnoses occurred in the Emergency Department; fewer than 33% of patients had any outpatient follow-up care prior to their readmission.

Researchers found that 92 of the 127 patients were misdiagnosed with healthcare associated pneumonia using CDC/National Healthcare Safety Network criteria. Healthcare associated pneumonia is a newly recognized form of pneumonia in patients who had recent close contact with a healthcare system, either through a hospital, outpatient dialysis center, nursing home or long-term care facility. The classification was added with the shift from hospital-based care to home-based care. This also points to the importance of using X-ray for ruling out pneumonia.

Surgical suite storage needs strategic touch

by Susan Cantrell, ELS

Does the supply storage area of your operating room resemble something that could be profiled on the cable television show "Hoarders"? If OR staff can’t, at a glance, look at their inventory and see what they need when they need it, they’re about to face some tense situations with supply chain management.


The OR comes with its own challenges. Storage space and inventory management are two prime problems. Eric Schuldt, vice president of sales and marketing, LogiQuip LLC, talked to Healthcare Purchasing News about difficulties that can arise concerning storage for OR supplies. "Some of the biggest challenges include maximizing the use of valuable OR space for supply storage; providing supply organization that eliminates wasted time by the OR staff looking for particular inventory items; maintaining appropriate par levels without having hoarding, stock outs, or product obsolescence; having storage products that enhance good infection-prevention practices by eliminating dust, dirt, and debris traps; and providing appropriate storage for instrument containers and wrapped instrument sets."

OR clean core using wall-mounted PAR WALL by LogiQuip

OR clean core using wall-mounted PAR WALL by LogiQuip

Limited space dedicated for OR supply storage coupled with ever-growing technology add to the troubles, noted Dave Salus, group manager, clinical products and medication management, InterMetro Industries Corporation: "Technology is evolving, types of procedures are expanding, and the supplies required to keep up with both are growing. Storage is typically the last space planned, forcing many OR supervisors and materials managers to work with what they have."

Keys to quality

What are the keys to a successful supply-storage improvement project? Salus offered a comprehensive overview: "Proper planning is key, including having a good understanding of what supplies are critical to support the OR. Workflow space should also be flexible enough to grow and be reconfigured to meet future plans."

To manage processes and inventory, healthcare facilities are increasingly turning to tried-and-true techniques and philosophies, such as LEAN management, gemba, the 5S’s, Six Sigma, and kanban.

• LEAN management focuses on reduction of waste, inventory, and response time. Gemba and the 5S’s are tools of LEAN management.

• The Japanese word "gemba" can mean several things. One definition is "the real place or the real thing." It’s based on the premise that problem solvers should first strive to understand the problem by immersing themselves in the work, at the location where the work is performed, to get the real facts of the matter before determining a solution.

• The 5S’s stand for sort, by clearing the work area; set in order, by designating locations; shine, through cleanliness and workplace appearance; standardize, with everyone doing things the same way; and sustain, by ingraining the 5S’s into the culture. Goals of the 5S’s are reduced set-up times; reduced cycle times; increased floor space; lower safety incident/accident rate; less wasted labor; and better equipment reliability.

• The philosophy of Six Sigma is based on identifying and fixing defects in the company’s processes, which lead to improved operational performance. It emphasizes process cost reduction, cycle-time improvement, less waste of materials, a better understanding of customer requirements, increased customer satisfaction, and more reliable products and services.

• Kanban is the Japanese word for "visible record," such as a sign or card. Traditionally, kanban cards are stored in a container, such as a bin, that holds the items. The worker holds up the card to indicate he or she wishes to pull a product from a bin. The card also provides information used for reordering the item. It’s a materials-requirement planning technique, an inventory control system, for tracking the flow of in-process materials through the operations of a just-in-time production process.

Southwest Solutions Group’s pass-through cabinets allow restocking from outside the OR, limiting exposure to contaminants.

Southwest Solutions Group’s pass-through cabinets allow restocking from outside the OR, limiting exposure to contaminants.

Schuldt, LogiQuip, observed: "The application of LEAN inventory-management techniques are gaining favor throughout the hospital supply chain, including the organization and management of inventory items used in the OR. Implementing LEAN tools, such as 5S’s and kanban pull systems, is becoming increasingly frequent due to the numerous benefits that can be obtained."

Stanley InnerSpace is another company that practices LEAN management. Shannon Kennedy, director of marketing, emphasized the importance of solutions reached by hands-on involvement rather than by just talking out the problem by people who may not fully understand the implications and complications. Kennedy believes that management buy-in is important, along with gemba.

"LEAN storage and inventory-management consulting is what we do every day," said Kennedy. "We don’t walk into a suite and wonder, ‘how many more cabinets can fit in this room?’ Instead, we try to understand why the department is bursting at the seams when they already have more than enough storage units. The best way to save money is to maximize what you already have. LEAN is a continual improvement process. There’s no stopping point, but there must be a starting point."

Very simply, explained Kennedy, "The Japanese word gemba means ‘go and see,’ and it’s just one foundational element necessary for a facility to embrace, at every level of the organization, when attempting to apply LEAN in healthcare. Don’t sit in a conference room and talk about how to fix a problem; go to where the work is done and interview the front-line staff. The clinical staff needs to be empowered to make changes."

After a Stanley InnerSpace 5S Project. Items such as sutures, tapes, and Tegaderm have a defined location with established par levels.

After a Stanley InnerSpace 5S Project. Items such as sutures, tapes, and Tegaderm have a defined location with established par levels.

Kennedy underlined her point with an anecdote: "During a LEAN consulting project, we were trying to understand why the OR staff had to leave the suite to get supplies when there were two cabinets filled with supplies already in the room. As we began to ask questions, it became obvious that the department didn’t have an effective process for keeping cabinets organized. This hampered both item retrieval and restocking. The cabinets were completely unorganized, items were just thrown in the trays, and there was no consistency between rooms. The nurses admitted it was easier to walk to the core than to look in the cabinets."

"We reconfigured the cabinets in one OR suite to test our solution. Each item that needed to be in the room was given its own location, each location was clearly labeled, and a par level was determined. The department worked with the cabinets for 1 week to confirm they were happy with the setup, and then the solution was applied to the remaining suites. Now that everything is clearly labeled and easy to find, trips to the core have been minimized, and the night staff has the ability to restock the cabinets with confidence. Ultimately, the department is happy, because they were able to solve an issue that had existed for over 3 years."

Suzanne Alexander-Vaughn, product manager, perioperative and supply solutions, Omnicell Inc., also encourages involving staff for best results. "Active involvement of staff who will be using the product on a daily basis is imperative. A clear delineation of goals from management is also necessary. Understanding that there may be smaller steps required to achieve the ultimate goal will allow for early successes on which a project can build."

Alexander-Vaughn cited one of Omnicell’s experiences with a client: "Without having to manually count inventory or key in charges, materials management staff at Patewood Memorial Hospital, in Greenville, South Carolina, can now focus on picking and auditing cases, allowing the clinical staff to focus on their respective areas of expertise. The hospital has seen at least two full-time employees reallocated to different areas 2 to 3 days a week as a result of the improved efficiency. Geoff Hibbert, OR manager at Patewood Memorial said: "Using Omnicell’s OptiFlex SS, we have weaned all scrub techs and nurses from picking cases. Materials distribution staff does it now."

Southwest Solutions Group uses the quality-management program Six Sigma along with kanban. David Myers, GAC LEED liaison and healthcare division manager, explained how they apply Six Sigma and kanban: "Southwest Solutions Group implements kanban and Six Sigma manufacturing efficiency methodologies into surgery centers to improve their bottom line and limit the exposure to infectious germs in their operating rooms. Efficient surgery centers incorporate storage systems to maximize the use of available space and enhance the productivity of personnel in three key areas. These areas include storage inside the procedure room, supply storage outside the procedure room, and surgical kit prep area."

What’s available

There is so much help available to maximize use of storage space in the OR and for managing inventory. Healthcare Purchasing News asked several vendors to describe their product and tell how it works to help ORs improve their efficiency.

The MetroMax i high-density Top-Track  maximizes space and increases capacity.

The MetroMax i high-density Top-Track maximizes space and increases capacity.

Storage solutions

In this case, putting first things first means making best use of the storage space allotted for the inventory. Salus talked about what InterMetro Industries can do for clients: "Metro’s consultative sales team, equipped with planning tools and well-designed storage systems, enables hospitals to make the most effective use of limited space for managing inventory while enabling staff to work efficiently with ready access to the supplies they need to provide quality care."

Metro offers a variety of solutions: the high-density Top-Track converts wasted aisle space into storage units. For smaller areas, there is the Starsys system, which has full-extension shelves to eliminate wasted access space above supplies. SmartWall Plus offers hooks, baskets, and shelves for versatile storage above equipment.

"As hospitals look for ways to contain costs and improve efficiency, managing supply inventories is an important issue," said Salus. "This was the case when not-for-profit healthcare system Union Hospital in Terre Haute, Indiana, designed its Advanced Surgery Center with a long, somewhat narrow, space devoted to the central core in the OR."

"Using CAD drawings of the planned area, Metro helped build a storage system to maximize available space, using its MetroMax i high-density Top-Track system, which increases the capacity of a given area by up to 50%. The system met Union Hospital’s needs to move storage units easily, even when stocked with heavy loads of up to 900 pounds, and to be reconfigured easily as demands change."

"When Union Hospital opened its Center, it reached its goal of storing 98% of supplies inside the central core. That success enables surgical teams to access supplies more conveniently and enhances flexibility to meet fast-changing medical challenges. In addition, it is making a significant impact on the hospital’s bottom line by improving efficiency, freeing up space otherwise used for storage, and eliminating wasted supplies."

Southwest Solutions Group offers antimicrobial, powder-coated steel or stainless-steel pass-through wall cabinets that can be stocked from outside the operating room. "Pass-through cabinets allow re-stocking from outside the OR even while a procedure is being conducted," said Myers. "Pass-through cabinets limit exposure to contaminants by reducing intrusions into the operating room. If pass-through cabinets cannot be incorporated, then non—pass-through cabinets can be used to create the same function, except re-stocking occurs after each procedure."

Myers continued: "Storage of surgical supplies outside the OR can be doubled, in most cases, with sliding or rolling high-density –storage shelving units. These compact storage units typically support several rooms and ensure critical supplies will be available when needed."

Southwest Solutions Group also offers automated preparation of surgical kits with carousels. Myers described them: "Horizontal carousels are powered spinning shelves that bring kit items to the operator at a sterile pick station. Horizontal carousels use inventory-management kitting software to increase operator productivity and accuracy, and to manage stock counts of inventoried supplies. Horizontal carousels use up to 80% less floor space compared to traditional shelving with plastic bins."

Schuldt, LogiQuip, described some of the products they offer: "LogiQuip’s LogiCell product line is available as built-in stainless-steel cabinetry or as a mobile cart line. Protected, easily accessible, well-organized, high-density storage is the result. Wasted space associated with flat-shelf –storage cabinetry is eliminated. Procedure-specific supply carts can be created that also include general supplies used frequently in OR procedures. Staff time, especially the circulating nurse’s, looking for supplies is greatly reduced."

"For storage in areas such as OR clean cores," continued Schuldt, "LogiQuip’s PAR WALL and PAR STOR provide open or drawer-type storage systems with wire baskets that are configurable to accommodate different SKU physical sizes and par levels. Each product line provides for exceptional supply storage compression along with superb supply organization and identification. Specialized storage products for suture, IV solutions, and mechanical-instrument storage are available, in addition to high-density, floor-mounted track systems for traditional wire shelving. Specialized LogiCell carts can be used for implant storage to better organize, identify, and control the different types and brands of implants. Wrap instrument sets should not be stacked onto each other and should be stored on shelving that won’t tear the wrap. LogiCell provides storage for both instrument containers and wrapped instrument packs that accommodate the unique storage needs of both."

Marc G. Higgins, director, materials management, St. Joseph’s Hospital, Eureka, CA, described the impact that LogiQuip’s systems had on them: "Converting our supply areas to LogiQuip’s systems has had a profound impact on supply chain’s ability to support clinical operations at our facilities. We had older rooms that were not designed as supply areas and were a root cause of stock outs and frustration for materials-management staff and our patient-care customers. LogiQuip’s specialized systems allowed us to significantly increase the storage capacity in these areas and reduce stock outs in par inventory areas to a statistical anomaly. LogiQuip also provided services such as onsite analysis and CAD drawings, and worked closely with me to understand our needs. Our clinicians love the LogiQuip systems, or at the very least the service improvements they helped us achieve."

Omnicell’s OptiFlex SS software manages products and provides visibility to stored items.

After a Stanley InnerSpace 5S Project. Items such as sutures, tapes, and Tegaderm have a defined location with established par levels.

Inventory management

Maximizing use of space is important but it doesn’t tell the whole story. Management of inventory presents its own challenges. Stanley InnerSpace offers a web-based inventory system. Kennedy explained: "Inventory management continues to be a challenge in the OR. Knowing what to order and when, and how and where to store supplies is something that inventory coordinators must deal with each day. A web-based inventory system like SpaceTRAX allows the department to apply the appropriate technology solution – barcode, RFID, or both – without asking the clinical staff to overhaul their current workflow. Unlike closed-cabinet solutions, you don’t need to remove existing cabinets and spend capital-equipment dollars to start recognizing immediate savings."

Kennedy described the virtues of SpaceTRAX: "Stanley InnerSpace inventory systems are designed to increase charge capture, eliminate waste, and reduce manual labor involved with managing inventory. With a user-friendly dashboard and a robust reporting engine, SpaceTRAX provides visibility into inventory spend, par-level optimization, item expirations, procedure cost by physician, and what should actually be on the physician preference cards. With a better understanding of your on-hand supplies, it’s easier to reduce the overall storage footprint and simplify the replenishment process."

Omnicell offers inventory-management software. Alexander -Vaughn explained how it works: "Omnicell’s OptiFlex SS software manages products based on items on preference cards and provides visibility to what is on the shelf at any point in time. Knowing what is at the hospital and having a view to what is used on a regular basis, what is not moving, what is expiring, and what may be needed for a scheduled case in the future are all integral components. Bidirectional interfacing with clinical systems allows data to be shared efficiently, and interfacing with other systems means time spent keying data can be more effectively utilized."

Alexander-Vaughn continued: "Management of implantables and other high-cost items remain a key challenge for supply management in the OR. Maximizing the physical space available with the appropriate level of supplies is also important. The Omnicell Tissue Center solution excels at managing implants, and the associated information needed to track them, and helps optimize inventory turns to ensure appropriate items are available when needed. Omnicell also understands different storage needs based on product type and can manage the source of supply replenishment effectively for an OR."