Successful surgical tray and kit planning requires committed communication and collaboration between surgical staff, physicians, central sterile/sterile processing department (CS/SPD) professionals and even supply chain. In this article, industry experts suggest how to design kits and procedure trays to enhance and support clinical and workflow effectiveness and efficiency. We also feature case studies from healthcare organizations that have implemented solutions for tray planning success.
Collaboration and communication
With over 25 years of experience addressing endoscopic instrumentation and sterilization challenges from a worldwide perspective, J. Jay Houser, CTS Consultant Sterilization, says surgical tray planning requires a buy in from everyone. He believes laying out the initial trays requires agreement with the operating room (OR) staff, CS/SPD staff, surgeons, materials management, and even biomed, and points out how logical placement of instruments as they are used by the surgeon makes it easier on the scrub nurse to anticipate what he/she needs next.
“Personally having spent over 20 years in operating rooms, I have too often seen a surgeon ask for an instrument and watched the scrub nurse search through the tray,” said Houser. “Organization with silicone brackets or device separators makes it easy to identify, count, and flag any instrument. A tray of instruments can be simple or complex and multilayered so planning is important. I think the best way is to lay a set out on a cut out of a tray and organize the instruments on the paper. Then, a tray can be designed using the appropriate holders. Throwing everything into a tray on top of a silicone mat offers nothing but frustration to everyone, CS/SPD, OR, surgeons, and materials management when they have to purchase yet another replacement for a broken instrument.”
According to Aerienne Cunningham, Director of Marketing for Case Medical, communication is the critical first step in successful tray planning. She encourages facilities to involve OR, CS/SPD and surgeons when establishing kits and procedure trays so that the trays are representative of what is actually used during a procedure. Cunningham points to a recent hospital study that showed how up to 60 percent of instruments contained in some orthopedic sets are rarely used in surgical cases.1 This extra instrumentation contributes to unnecessary reprocessing, and unwanted items add to the weight to the set.
“Removing unnecessary instruments has been proven to reduce reprocessing time and increase efficiency,” said Cunningham. “At Case Medical, we actively look for ways to enhance and support clinical workflow by engaging staff and surgeons to reduce inventory by creating build-to-order sets based on surgeon’s preference cards and pick lists. Instrument tracking system software, such as Case Medical’s CaseTrak360 and LoanerLocate, helps facilities organize and create sets based on what is truly needed for surgical procedures. The same concept can be applied to custom kits and supplies.”
Physician preference cards: recipe for success
Referred to as the “recipe cards” for surgical trays, physician preference cards are a critical component for tray planning success. University of Tennessee Medical Center (UTMC) and Mercy are two examples of healthcare organizations that have leveraged their physician preference cards to drive greater efficiency, cost savings and patient safety.
The UTMC smart trash can
Upon analyzing the accuracy of their case carts, UTMC found between 50 to 70 percent of items pulled for a case were returned to stock. This resulted in excess inventory, manual labor wasted on picking unnecessary supplies and returning them to stock, and inaccurate charge capture. The movement of supplies and clinicians into and out of the OR also disrupted patient care and increased the risk for patient infection.
To overcome these challenges, UTMC partnered with DeRoyal on an initiative to develop the “perfect physician preference card.” They developed a smart trash can called Optimized Supply Capture and Reconciliation (OSCAR) that is equipped with software to read radio frequency identification (RFID) tags on product packaging. As the packaging is discarded into OSCAR, the solution captures unique product information and transmits it to UTMC’s OR software system, which serves as the patient’s medical record. The solution helps to easily determine the supply charges generated for each surgical case. Using OSCAR, UTMC’s capture rate has improved to 99.8 percent on RFID-tagged items.
UTMC has used the data collected from OSCAR to increase efficiencies throughout their medical center. OSCAR accurately reports which supplies from the physician preference cards are used during procedures to improve the accuracy of physician preference cards. With accurate preference cards, UTMC achieves greater efficiencies overall, including more effective inventory management, lower costs, improved patient safety, and more accurate Unique Device Identification (UDI) and charge capture. To read the full case study, visit the Association for Healthcare Resource & Materials Management (AHRMM) Learning UDI Community Resource Center: http://www.ahrmm.org/knowledge-center/resources/case-study/university-of-tennessee-medical-center-udi-capture-case-study-2017.
The Mercy perpetual inventory system
When Mercy hired Betty Jo Rocchio, CRNA, MS as Vice President, Perioperative Performance Acceleration, one of her first actions to improve perioperative performance was to address physician preference cards. She and her team engaged in a yearlong project to “lean up” Mercy’s preference cards – ensuring the products contained within the cards matched the surgeons’ needs. While they were able to reduce supply expense by up to $6 million, Rocchio and her team soon realized the preference cards they had spent so much time manually “cleaning up” were once again outdated and inaccurate.
Rocchio approached Matthew Mentel, Mercy’s Executive Director, Integrated Performance Solutions, for help on the preference card challenge. Together they realized that they needed to view the preference cards as an inventory management tool rather than a ‘card’ that needs cleaning or scrubbing on a quarterly basis.
From there they embarked on a collaborative effort involving supply chain, clinical teams, the finance department, and information technology teams, in partnership with their technology supplier TECSYS, to develop a solution for perioperative inventory management. The result of this collaboration has been a perpetual inventory management system where clinical, operational and financial workflows are driven by preference cards. Through the TECSYS solution, which is integrated with Mercy’s Epic electronic health record (EHR) system and Infor’s Lawson enterprise resource planning (ERP) system, the health system is able to do the following:
- Use preference cards to drive product selection for a case
- Real-time updating improves accuracy
- Allocate the products as a procedure is being scheduled
- Enables projected supply demand for planning purposes
- Enables projected supply demand for planning purposes
- Pull the products for a procedure, build the case cart and have it ready for consumption when the clinician walks in the room
- Creates an “allocated” status for staged or pending inventory
- Decrement the products from inventory upon consumption, documents the return of unused products into inventory
- Provides inventory visibility across the care chain
- Document product usage in the patient’s clinical records
- Quantifies the cost of the procedure
Through their work Mercy anticipates that it will save between $11M – $13M over the next four years, while at the save time driving higher quality care and improved patient safety.
Standardization
Studies have shown that standardization of surgical equipment can reduce costs without impacting patient care quality or outcomes.2,3 But as Aaron Lieberman, CCSVP Marketing Manager for Summit Medical (an Innovia Medical Company), points out, instrument standardization is particularly challenging because a solution that works for one facility, or that is preferred by one surgeon within a facility, won’t always be ideal for another. He stresses the need to pull together the right stakeholders.
“The first step to success in procedure tray planning is to gather a team of stakeholders that consists of instrument coordinators, OR managers, surgeons and CS/SPD professionals,” said Lieberman. “Once the team has been formed, it should look toward the CS/SPD representatives for leadership because of their expertise in instruments, trays and reprocessing. After identifying the needs of each of the represented stakeholders, the CS/SPD team members can then determine the best strategy for executing their plan.”
Summit Medical offers custom tray solutions to help with standardization. Made of durable, highly perforated aluminum and silicone instrument holders, the company’s InstruSafe Trays secure delicate instruments with 360 degrees of protection during sterilization, transportation, storage and the OR. Because the trays are fully customizable, they can accommodate a wide range of needs. Furthermore, because they are cleared for a variety of FDA 510(k) sterilization cycles, they are an easy upgrade for use with both wrap and rigid containers.
The role of supply chain
A challenging aspect for surgical kit planning is balancing the needs of individual practitioners and the need of the facility to have a cost effective program, explains Suzanne Champion, RN, BSN, MBA, CNOR, Director Clinical Operations, Cardinal Health. She points out how the entire supply chain has a direct impact on overall clinical and workflow effectiveness and efficiency. Therefore, supply chain professionals must collaborate with clinicians to understand their supply needs, where to store them for maximum efficiency, and how to move them through the system from the receiving dock to the end user.
“If any part of this process is broken or deficient (i.e. kits with waste or minimal components, outdated or incomplete preference cards, a case pick process that is not managed properly, inventory levels that do not meet procedural needs) the end result is decreased clinical and workflow efficiency,” said Champion.
According to Kari Cashmore, Director of Marketing, Cardinal Health, surgical kits are one of the first places facilities look to reduce costs, and many ask to simply remove items from surgical packs. But as Cashmore points out, this approach can backfire.
“Some believe that eliminating supplies from kits is the fast-tracked path to saving money,” said Cashmore. “However, if you remove necessary supplies from your surgical packs, but are still pulling them from the shelf, they are still costing you money. And now there is an additional pick, which can negatively impact your workflow and efficiency.”
“Your surgical kit program is a key portion of the supply chain that needs to have the most attention, but you cannot focus on just the kits and expect the most clinical and workflow effectiveness and efficiency for your facility,” Champion added.
Cardinal Health’s Procedural Supply Chain Assessment addresses both surgical supplies and workflows. The company’s onsite assessment led by its clinical and supply chain experts helps hospitals and surgery centers identify cost saving and standardization opportunities at the component, pack and procedural level. In doing so, healthcare facilities can reduce waste, improve efficiencies and ultimately reduce costs. For more information, contact a local Cardinal Health representative or [email protected].
Loaner trays
Loaner trays present their own set of challenges when it comes to surgical tray planning. As Inova Fair Oaks Hospital had grown in surgical volume, particularly for orthopedic and spine procedures, their loaner tray volume increased as well. According to Mead Mulvihill, Director of PeriOp Support Analytics for Inova Fair Oaks Hospital, not only was the coordination of bringing these trays into the facility cumbersome, often times trays were delivered less than 24 hours before surgery.
“We were able to statistically prove a correlation between the number of loaner trays delivered less than 24 hours before a case and a significant rise in defects such as bioburdens,” said Mulvihill.
To help combat these issues, Fair Oaks implemented VenSero, an online solution that automates the ordering and communication surrounding loaner trays with outside vendors. Mulvihill explains that the solution has allowed his team to identify which loaner tray vendors are not complying with their policies on tray delivery. It also alerts them to late tray check ins.
“Utilizing this data we have been able to drive compliance with trays being delivered 24 hours or more before surgery,” said Mulvihill. “We have seen our numbers in six months go from 20 percent to 30 percent of trays on time to 70 percent to 80 percent. Overall it has helped us better coordinate and reduce stress on the staff to ensure that everything needed for a case arrives appropriately.”
Placement counts
While surgical instrument tray prep is critically important, ensuring all instruments and supplies are accounted for post-surgery is equally essential to patient safety. The Joint Commission reports that unintended retained foreign objects (URFOs) are the most frequent sentinel event reported to its Sentinel Event database, with 115 URFOs reported in 2015, up from 102 in 2013.4
The practice of perioperative sponge, needle and instrument counts can help prevent URFOs. The Joint Commission recommends that healthcare facilities standardize count policies for all procedures, not just those involving an open chest or abdomen.4 Count sheets help facilitate this but there have been questions about the safety of including printed sheets within wrapped trays or containers. The Association of periOperative Registered Nurses’ (AORN) states:
“Count Sheets should not be placed inside wrapped sets or rigid containers. Although there are no known reports of adverse events related to sterilized count sheets, there is no available research regarding the safety of toners and/or various papers subjected to any sterilization method. Chemicals used in the manufacturer of paper and toner ink pose a theoretical risk of reaction in some sensitized individuals.”5
To address this challenge, Healthmark has developed a variety of count sheet holders that safely hold the sheets on the outside of sterilization trays. The company has two options for wrapped trays: a transparent poly front sheet holder with a medical grade paper back, and a medical grade paper pouch holder that adheres to the side of the wrapped tray. For rigid sterilization containers Healthmark offers a slotted tray label that allows for the count sheet to be attached to the outside of a closed container.
References:
- Surgery Setup: Making a Difference for People, Safety and Costs, https://www.virginiamasoninstitute.org/
- Standardization of operative equipment reduces cost. J Pediatr Surg. 2013 Sep;48(9):1843-9. doi: 10.1016/j.jpedsurg.2012.11.045. https://www.ncbi.nlm.nih.gov/pubmed/24074655
- A Model of Cost Reduction and Standardization: Improved Cost Savings While Maintaining the Quality of Care. Dis Colon Rectum. 2015 Nov;58(11):1104-7. doi: 10.1097/DCR.0000000000000463. https://www.ncbi.nlm.nih.gov/pubmed/26445185
- Strategies to prevent URFOs, The Joint Commission, January 2016.
- AORN 2011 Recommended Practices for Selection and Use of Packaging Systems for Sterilization Recommendation (IV #3)
Kara Nadeau | Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.
