- Email: [email protected]
OR Procedure Packs
JULY 1988, VOL. 48, N O I
AORN JOURNAL
OR Procedure Packs A COST-SAVING APPROACH
Carol Gellman, RN
I
n the current health care environment, perioperative nurses are faced with the challenge of finding innovative and creative means to contain costs and increase productivity. Using custom OR procedure packs to contain costs is one method to help nurses meet that challenge. A custom OR procedure pack is a single, sterile, customized, disposable pack containing all the supplies needed for a surgical procedure. It is assembled by the vendor to the specifications of the health care facility. With this system, there is only the one pack to order, transport, store, and open. Custom packs can save costs in purchasing, material transportation, inventory, and utilization.
through its 15 operating rooms. In 1985,nurse administrators decided to use a commercially prepared disposable custom pack system. In the past, nurse administrators ordered individual supplies in bulk. But ordering these supplies, maintaining inventory, stocking, and pulling items absorbed valuable time that could have been used in a more productive manner.
Cost Savings Ibchasitzg. Savings from the custom pack begm
Background
F
or many years, central processing departments have assembled and sterilized reusable packs and kits. With improved technology, commercially prepared disposable products became more attractive to institutions. In the 196Os, vendors began producing simple packs (ie, suture removal trays and skin prep kits) that proved convenient and cost-effective. The trend continued as health care costs rose in the 1970s and 1980s, and institutions were forced to find more costcontainment measures. As a result, the demand for custom-made OR packs increased. The Memorial Sloan-Kettering Cancer Center in New York City is a 565-bed,metropolitan hospital with an OR department that schedules approximately 12,000surgical procedures per year 12
Carol Gellman, RN, MSN, k the assktant director of the OR, Memorial Sloan-Kettering Cancer Center, New York City. She earned her diploma in nursing at Beth Israel Medical Center School of Nursing, New York City, her bachelor of science degree in nursing from the State University of New York at Albany, and her master of science degree in nursing adminktrationfrom Hunter-Bellevue School of Nursing, New York City.
J U L Y 19XX. VOL. 48. NO I
with the purchase order. By combining individual items into one custom pack, it decreases the number of purchase orders. Instead of ordering from several different vendors on an “as needed” basis,just one purchase order is used for the custom pack. Cost savings can be evaluated by comparing the cost of the purchase orders generated monthly to obtain the individual supplies with the cost of a single purchase order for the pack. The cost of processing a purchase order varies. At Memorial Sloan-Kettering Cancer Center, the administrative cost of processing a purchase order is approximately $75. For a custom thoracic surgery pack containing 20 items, the purchase order charge is $75. To order the individual items, 20 purchase orders would be needed, which amounts to $1,500. If packs are used, it can add up to a monthly savings of $1,425, or a yearly savings of $17,100. If your institution does not have a dollar value for processing a purchase order, use the average cost of $25.’ With a 20-item thoracic surgery pack, monthly savings will be $475. Either way, this represents a significant savings in indirect purchasing costs. Another purchasing advantage includes streamlining patient charges. Custom packs will help standardize supplies and capture lost revenue. Often, these charges are forgotten or lost in paperwork. Custom packs can help to capture these charges, because only one item is charged. It is easier to audit a lost charge for one pack than 20 lost charges for individual items. Material transportation. Handling a custom pack can streamline distribution of supplies throughout the facility. Usually, items are held or stocked in general storage areas, central processing departments, OR storage areas, and operating rooms. These departments can save both time and labor costs involved in moving products from different departments, receiving stock and shelving items, and building case carts. These savings are due to a reduction in the number of items received or requested and the time it takes to transport them. Inventory. Custom packs minimize holding and storage costs incurred by the institution. A holding cost is the potential interest lost from money tied
A OR N J O U R N A L
Neuro Custom Pack Contents 1 overhead table cover 4 44 x 58 half sheets 3 polylined absorbable towels 3 Mayo stand covers 4 packs (10) 4 x 8 sponges, x-ray detectable 2 bulb syringes 1 skin marker with ruler 2 packs bone wax 8 #32 rubberbands 4 #10 blades 1 #I 1 blade 2 # 15 blades 1 10 cc Luer-Loc syringe 1 20 cc Luer-Loc syringe 1 pack ( 5 ) large cotton balls, x-ray detectable 1 pack (5) medium cotton balls, x-ray detectable 5 %inch cotton balls with string 10 38 x 3 neuro cottonoids 10 Yt x 3 neuro cottonoids 10 41 x 3 neuro cottonoids 10 1 x 3 neuro cottonoids 2 suction tubings 1 foam needle counter, 40count up with too much inventory. Every institution has a dollar value for storage space. To estimate a cost saving, subtract the space the packs need from the space individual items need. Multiply the space differenceby the dollar value to get the cost saving. To save even more money, find a vendor that can warehouse the packs for you. Keeping track of inventory also is easier for both manual and computerized systems. If a computerized system is used, the amount of data input is greatly decreased, which frees clerical personnel for other tasks. Utilization. The most apparent benefit from custom packs is the time saved to set up for a surgical procedure. Opening a single sterile pack containing all the necessary components for a procedure takes much less time than opening each individual item. The neuro pack, for example, contains 23 different items. (See “Neuro Custom Pack Contents.”) It takes approximately three minutes to open the pack compared to 12 minutes 73
JULY 1988, VOL. 48, NO 1
AORN JOURNAL
Estimates of labor and time savings from using the custom packs must be realistic to offset their disadvantages. to open the individual items. Add this time over several cases,and the savings will be considerable. All members of the surgical team benefit from the custom packs. The staff nurses benefit from the decrease in work effort and movement; surgeons benefit from minimal interruptions during procedures; and nurse managers benefit from the increase in staff productivity. The greatest benefit, however, is the additional time available for providing direct patient care.
Selecting a Vendor
A
vendor of custom packs needs to have some specific qualities. The company must be familiar with the OR to understand your needs and must be able to assemble and warehouse the packs as specified. It also helps ensure fast delivery if the company’s warehouse is close to your facility. The company must be able to ensure that the product is sterile and delivered as specified in the contract, have a quality assurance program for its products, and be able to adapt to changes. A competent sales representative or contact person at the company must be available to gather information and solve problems. The company also should be able to provide research material. After selecting a vendor, the next step is to assemble the components for the pack. Specific catalog and vendor numbers of the items are important because of the wide variety in the quality of items. If the vendor wants to substitute an item, make sure you use it on a trial basis first. At Memorial Sloan-Kettering Cancer Center, selecting pack components required extensivestaff participation. The nurse managers, who each had specific requests, met to standardize packs that could be used for a number of different surgeries. After much discussion, they developed eight packs: minor, major, neuro, mastectomy, head and neck, lithotomy, thoracic, and orthopedic. 74
Trial Use
0
nce the pack lists were developed, nurse administrators instituted a clinical trial. An evaluation of each pack was done by several staff members on different levels (ie, staff nurses, nurse managers). The following are important points to consider when performing a clinical trial: imperviousness of pack, ease of opening, maintenance of sterility, size of outer wrapper cover (needs to be large enough to cover the table adequately), visibility of sterile label, completeness of contents, and organization of pack. After the packs were approved, nurse managers estimated their need and placed a six-month order of custom packs.
Disadvantages
T
here are disadvantages to the custom packs. The price of each pack is more than the sum of the individual items. Although the packs offer substantial time and labor savings, it is difficult to quantify the savings because most are indirect savings. Another disadvantage is wasted items. If an item in the pack is unacceptable, it is discarded and a substitute item used every time a pack is opened. Because the packs are prepared in large quantities in advance, it may take up to three months before changes can be made in the pack items. In addition, if a pack is damaged before opening, the cost of the waste is much higher than wasting an individual item. The decision to use custom packs must be carefully evaluated. Estimates of labor and time savings must be realistic to offset the disadvantages of the packs.
J U L Y I9XX. VOL. 4X. NO I
Implicationsfor Nursing Research
T
he use of custom OR packs has several implications for perioperative nursing research. The AORN “Recommended practices for basic aseptic technique” states, “All items introduced into a sterile field should be dispensed by methods that maintain sterility of the item and integrity of the sterile field.”* With individual items, it is difficult to assess whether all the items introduced into the sterile field are always introduced in a sterile manner. Custom packs can ease those doubts by reducing the number of items introduced into the sterile field. Nursing research is needed to evaluate the effectiveness of custom packs in preventing postoperative wound infections. Another area for research is the effect of custom OR packs on productivity and utilization.
AORN JOURNAL
OPERATING ROOM CLINICAL INSTRUCTOR Acute teaching & research hospital seeks an individual to serve as Clinical Instructor in our 10-suiteoperating room. Incumbent will be responsible for Post Graduate Nursing O.R. Program, Medical Student Orientation Program, O.R. Nursing Orientation and ContinuingEducation. Requires Master’s degree in Nursing and minimum 2 years’ clinical &teaching experience in the operating room. For more information please contact:
Universityof California 225 Oickinson Street (H-692)
Summary
C
learly, custom OR procedure packs can reduce costs, increase efficiency, and increase productivity. Indirect savings in purchasing, transporting material, inventory, and utilization will dramatically add to the benefits of the custom packs. The saving that has the most positive effect, however, is the time made available to deliver perioperative patient care.
(619) 543-6260
AA/EOE
CARDIAC RN’S All Children’s Hospital is looking for energetic,
skilled Cardiac Nurses for our expanding Surgery Department In our fast-paced OR, you will work with both pediatric and adult patients, utilizing the latest in technology, equipment and procedures.
2.
Located in St. Petersburg, we are a JCAH accredited, teaching and research facility, and the only hospital of its kind on Florida’s beautiful west coast We offer an outstanding benefits package which includes paid medical, dental, and life insurance, a liberal paid time off program, tuition reimbursement, competitive salaries, and much more. In addition, you will experience recognition and respect for your abilities, along with opportunities to broaden your knowledgeand challenge your skills.
Suggested reading Hogan, J. “Streamlining patient care with the two pack system: OR cost containment.” Today’s OR Nurse
Become a member of a team that is on the leading edge. Call Emily Williams, collect, (813) 892-4422, or send resume to Personnel:
Notes 1. S F Heinritz, P V Farrell, Purchasing: Principles andApplicutions,6th ed (Englewood Cliffs, NJ: Prentice Hall, 1981) 54. 2. “Recommended practices for basic aseptic technique,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1987) 111: 2-
8 (February 1986) 27-29. Kinney, G J; Lutjens, L R. “Cost accountability in the OR: A case for custom-designed, procedure-ready packs.” AORN Journal 43 (June 1986) 1306-1310. Twomey, T. “OR custom packs No easy answers.” Hospital Materials Management 11 (May 1986) 813.
801 Sixth Street South P.O. Box 31020 St Petersburg. FL 33731 EOE/MFHV 15
AORN JOURNAL
OR Procedure Packs A COST-SAVING APPROACH
Carol Gellman, RN
I
n the current health care environment, perioperative nurses are faced with the challenge of finding innovative and creative means to contain costs and increase productivity. Using custom OR procedure packs to contain costs is one method to help nurses meet that challenge. A custom OR procedure pack is a single, sterile, customized, disposable pack containing all the supplies needed for a surgical procedure. It is assembled by the vendor to the specifications of the health care facility. With this system, there is only the one pack to order, transport, store, and open. Custom packs can save costs in purchasing, material transportation, inventory, and utilization.
through its 15 operating rooms. In 1985,nurse administrators decided to use a commercially prepared disposable custom pack system. In the past, nurse administrators ordered individual supplies in bulk. But ordering these supplies, maintaining inventory, stocking, and pulling items absorbed valuable time that could have been used in a more productive manner.
Cost Savings Ibchasitzg. Savings from the custom pack begm
Background
F
or many years, central processing departments have assembled and sterilized reusable packs and kits. With improved technology, commercially prepared disposable products became more attractive to institutions. In the 196Os, vendors began producing simple packs (ie, suture removal trays and skin prep kits) that proved convenient and cost-effective. The trend continued as health care costs rose in the 1970s and 1980s, and institutions were forced to find more costcontainment measures. As a result, the demand for custom-made OR packs increased. The Memorial Sloan-Kettering Cancer Center in New York City is a 565-bed,metropolitan hospital with an OR department that schedules approximately 12,000surgical procedures per year 12
Carol Gellman, RN, MSN, k the assktant director of the OR, Memorial Sloan-Kettering Cancer Center, New York City. She earned her diploma in nursing at Beth Israel Medical Center School of Nursing, New York City, her bachelor of science degree in nursing from the State University of New York at Albany, and her master of science degree in nursing adminktrationfrom Hunter-Bellevue School of Nursing, New York City.
J U L Y 19XX. VOL. 48. NO I
with the purchase order. By combining individual items into one custom pack, it decreases the number of purchase orders. Instead of ordering from several different vendors on an “as needed” basis,just one purchase order is used for the custom pack. Cost savings can be evaluated by comparing the cost of the purchase orders generated monthly to obtain the individual supplies with the cost of a single purchase order for the pack. The cost of processing a purchase order varies. At Memorial Sloan-Kettering Cancer Center, the administrative cost of processing a purchase order is approximately $75. For a custom thoracic surgery pack containing 20 items, the purchase order charge is $75. To order the individual items, 20 purchase orders would be needed, which amounts to $1,500. If packs are used, it can add up to a monthly savings of $1,425, or a yearly savings of $17,100. If your institution does not have a dollar value for processing a purchase order, use the average cost of $25.’ With a 20-item thoracic surgery pack, monthly savings will be $475. Either way, this represents a significant savings in indirect purchasing costs. Another purchasing advantage includes streamlining patient charges. Custom packs will help standardize supplies and capture lost revenue. Often, these charges are forgotten or lost in paperwork. Custom packs can help to capture these charges, because only one item is charged. It is easier to audit a lost charge for one pack than 20 lost charges for individual items. Material transportation. Handling a custom pack can streamline distribution of supplies throughout the facility. Usually, items are held or stocked in general storage areas, central processing departments, OR storage areas, and operating rooms. These departments can save both time and labor costs involved in moving products from different departments, receiving stock and shelving items, and building case carts. These savings are due to a reduction in the number of items received or requested and the time it takes to transport them. Inventory. Custom packs minimize holding and storage costs incurred by the institution. A holding cost is the potential interest lost from money tied
A OR N J O U R N A L
Neuro Custom Pack Contents 1 overhead table cover 4 44 x 58 half sheets 3 polylined absorbable towels 3 Mayo stand covers 4 packs (10) 4 x 8 sponges, x-ray detectable 2 bulb syringes 1 skin marker with ruler 2 packs bone wax 8 #32 rubberbands 4 #10 blades 1 #I 1 blade 2 # 15 blades 1 10 cc Luer-Loc syringe 1 20 cc Luer-Loc syringe 1 pack ( 5 ) large cotton balls, x-ray detectable 1 pack (5) medium cotton balls, x-ray detectable 5 %inch cotton balls with string 10 38 x 3 neuro cottonoids 10 Yt x 3 neuro cottonoids 10 41 x 3 neuro cottonoids 10 1 x 3 neuro cottonoids 2 suction tubings 1 foam needle counter, 40count up with too much inventory. Every institution has a dollar value for storage space. To estimate a cost saving, subtract the space the packs need from the space individual items need. Multiply the space differenceby the dollar value to get the cost saving. To save even more money, find a vendor that can warehouse the packs for you. Keeping track of inventory also is easier for both manual and computerized systems. If a computerized system is used, the amount of data input is greatly decreased, which frees clerical personnel for other tasks. Utilization. The most apparent benefit from custom packs is the time saved to set up for a surgical procedure. Opening a single sterile pack containing all the necessary components for a procedure takes much less time than opening each individual item. The neuro pack, for example, contains 23 different items. (See “Neuro Custom Pack Contents.”) It takes approximately three minutes to open the pack compared to 12 minutes 73
JULY 1988, VOL. 48, NO 1
AORN JOURNAL
Estimates of labor and time savings from using the custom packs must be realistic to offset their disadvantages. to open the individual items. Add this time over several cases,and the savings will be considerable. All members of the surgical team benefit from the custom packs. The staff nurses benefit from the decrease in work effort and movement; surgeons benefit from minimal interruptions during procedures; and nurse managers benefit from the increase in staff productivity. The greatest benefit, however, is the additional time available for providing direct patient care.
Selecting a Vendor
A
vendor of custom packs needs to have some specific qualities. The company must be familiar with the OR to understand your needs and must be able to assemble and warehouse the packs as specified. It also helps ensure fast delivery if the company’s warehouse is close to your facility. The company must be able to ensure that the product is sterile and delivered as specified in the contract, have a quality assurance program for its products, and be able to adapt to changes. A competent sales representative or contact person at the company must be available to gather information and solve problems. The company also should be able to provide research material. After selecting a vendor, the next step is to assemble the components for the pack. Specific catalog and vendor numbers of the items are important because of the wide variety in the quality of items. If the vendor wants to substitute an item, make sure you use it on a trial basis first. At Memorial Sloan-Kettering Cancer Center, selecting pack components required extensivestaff participation. The nurse managers, who each had specific requests, met to standardize packs that could be used for a number of different surgeries. After much discussion, they developed eight packs: minor, major, neuro, mastectomy, head and neck, lithotomy, thoracic, and orthopedic. 74
Trial Use
0
nce the pack lists were developed, nurse administrators instituted a clinical trial. An evaluation of each pack was done by several staff members on different levels (ie, staff nurses, nurse managers). The following are important points to consider when performing a clinical trial: imperviousness of pack, ease of opening, maintenance of sterility, size of outer wrapper cover (needs to be large enough to cover the table adequately), visibility of sterile label, completeness of contents, and organization of pack. After the packs were approved, nurse managers estimated their need and placed a six-month order of custom packs.
Disadvantages
T
here are disadvantages to the custom packs. The price of each pack is more than the sum of the individual items. Although the packs offer substantial time and labor savings, it is difficult to quantify the savings because most are indirect savings. Another disadvantage is wasted items. If an item in the pack is unacceptable, it is discarded and a substitute item used every time a pack is opened. Because the packs are prepared in large quantities in advance, it may take up to three months before changes can be made in the pack items. In addition, if a pack is damaged before opening, the cost of the waste is much higher than wasting an individual item. The decision to use custom packs must be carefully evaluated. Estimates of labor and time savings must be realistic to offset the disadvantages of the packs.
J U L Y I9XX. VOL. 4X. NO I
Implicationsfor Nursing Research
T
he use of custom OR packs has several implications for perioperative nursing research. The AORN “Recommended practices for basic aseptic technique” states, “All items introduced into a sterile field should be dispensed by methods that maintain sterility of the item and integrity of the sterile field.”* With individual items, it is difficult to assess whether all the items introduced into the sterile field are always introduced in a sterile manner. Custom packs can ease those doubts by reducing the number of items introduced into the sterile field. Nursing research is needed to evaluate the effectiveness of custom packs in preventing postoperative wound infections. Another area for research is the effect of custom OR packs on productivity and utilization.
AORN JOURNAL
OPERATING ROOM CLINICAL INSTRUCTOR Acute teaching & research hospital seeks an individual to serve as Clinical Instructor in our 10-suiteoperating room. Incumbent will be responsible for Post Graduate Nursing O.R. Program, Medical Student Orientation Program, O.R. Nursing Orientation and ContinuingEducation. Requires Master’s degree in Nursing and minimum 2 years’ clinical &teaching experience in the operating room. For more information please contact:
Universityof California 225 Oickinson Street (H-692)
Summary
C
learly, custom OR procedure packs can reduce costs, increase efficiency, and increase productivity. Indirect savings in purchasing, transporting material, inventory, and utilization will dramatically add to the benefits of the custom packs. The saving that has the most positive effect, however, is the time made available to deliver perioperative patient care.
(619) 543-6260
AA/EOE
CARDIAC RN’S All Children’s Hospital is looking for energetic,
skilled Cardiac Nurses for our expanding Surgery Department In our fast-paced OR, you will work with both pediatric and adult patients, utilizing the latest in technology, equipment and procedures.
2.
Located in St. Petersburg, we are a JCAH accredited, teaching and research facility, and the only hospital of its kind on Florida’s beautiful west coast We offer an outstanding benefits package which includes paid medical, dental, and life insurance, a liberal paid time off program, tuition reimbursement, competitive salaries, and much more. In addition, you will experience recognition and respect for your abilities, along with opportunities to broaden your knowledgeand challenge your skills.
Suggested reading Hogan, J. “Streamlining patient care with the two pack system: OR cost containment.” Today’s OR Nurse
Become a member of a team that is on the leading edge. Call Emily Williams, collect, (813) 892-4422, or send resume to Personnel:
Notes 1. S F Heinritz, P V Farrell, Purchasing: Principles andApplicutions,6th ed (Englewood Cliffs, NJ: Prentice Hall, 1981) 54. 2. “Recommended practices for basic aseptic technique,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1987) 111: 2-
8 (February 1986) 27-29. Kinney, G J; Lutjens, L R. “Cost accountability in the OR: A case for custom-designed, procedure-ready packs.” AORN Journal 43 (June 1986) 1306-1310. Twomey, T. “OR custom packs No easy answers.” Hospital Materials Management 11 (May 1986) 813.
801 Sixth Street South P.O. Box 31020 St Petersburg. FL 33731 EOE/MFHV 15