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Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards
Accepted Manuscript Title: Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards Author: Lara F B Harvey, Katherine A Smith, Howard Curlin PII: DOI: Reference:
S1553-4650(17)30377-1 http://dx.doi.org/doi: 10.1016/j.jmig.2017.06.018 JMIG 3178
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
22-3-2017 7-6-2017 23-6-2017
Please cite this article as: Lara F B Harvey, Katherine A Smith, Howard Curlin, Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.06.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Harvey 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Title: Physician engagement in improving operative supply chain efficiency through review of surgeon preference cards
39
and transporting of unnecessary supplies by improving the accuracy of surgeon
40
preference cards.
41
Study Design: Quality Improvement
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Design Classification: Canadian Task Force Classification II-3
Authors: Lara F B HARVEY MD MPH1,3, Katherine A SMITH MD2, Howard CURLIN MD1 Division of Minimally Invasive Gynecology Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, TN 1
2Department
of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, TN 3Corresponding
author contact information: Lara Harvey MD, MPH Vanderbilt University Medical Center Department of Obstetrics and Gynecology 1161 21st Avenue South B-1100 Medical Center North Nashville, TN 37232-2519 Email: [email protected] Phone: (615) 343-7441 Fax: (615) 343-8881 The authors report no disclosures.
Precis: 30 words. A one-time surgeon review of preference cards at an academic medical center resulted in a decrease in the number of disposable and reusable instruments used in the operating room, potentially saving cost.
Abstract: Study Objective: To reduce operative costs involved in the purchase, packing,
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Setting: Gynecologic surgery suite of an academic medical center
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Participants: Twenty-one specialized and generalist gynecologic surgeons
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Interventions: The preference cards of up to the five most frequently performed
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procedures per surgeon were selected. A total of 81 cards were distributed to 21 surgeons
47
for review. Changes to the cards were communicated to the OR charge nurse and
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finalized.
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Measurements and Main Results: Fourteen surgeons returned a total of 48 reviewed
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cards, 39 of which had changes. A total of 109 disposable supplies were removed from
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these cards, totaling $767.67. The cost per card was reduced by $16 on average just for
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disposables. Three reusable instrument trays were also eliminated from the cards, which
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resulted in savings of about $925 in processing costs over three months. Twenty-two
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items were requested by the surgeon to be available upon request; however, not routinely
55
placed in the room at the start each case, totaling $6,293.54. The rate of return of unused
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instruments back to storage decreased after our intervention from 10.1 to 9.6 instruments
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per case.
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Conclusions: Surgeon preference cards serve as the basis for economic decision making
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about the purchase, storing, packing and transporting operative instruments and supplies.
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A one-time surgeon review of cards resulted in a decrease in the number of disposable
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and reusable instruments that must be stocked, transported, counted in the OR, or
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returned, potentially translating into cost savings. Surgeon involvement in preference
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card management may reduce waste and provide ongoing cost savings.
64 65 66 67
Keywords: cost; quality; surgeon preference card; laparoscopy; surgery
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Text:
69
Introduction: Healthcare spending is expected to reach 20.1% of the United State’s GDP
70
by 2025 [1]. Despite this, Americans suffer poorer health and shorter lifespans than
71
people in other high-income countries [2]. Discussions about the need to improve cost-
72
effectiveness and quality of medical care grow more urgent in numerous venues. The
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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the
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Sustainable Growth Rate formula and the new Quality Payment Program is prompting a
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renewed look at how to provide quality health care based on performance data in the
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most cost-effective manner possible. The journal Obstetrics and Gynecology recently
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introduced a new article type, Clinical Practice and Quality, addressing the imperative to
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further quality improvement research in obstetrics and gynecology. The accompanying
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editorial notes that meaningful venues for this important work have been lacking in
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obstetrics and gynecology [3].
81 82
In 2015, 32% of healthcare spending went to hospital costs, of which operating
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room costs are a part [4]. Decreasing supply waste in the operating room has been
84
pointed out as an avenue for improving efficiency. A recent study of neurosurgical cases
85
at Stanford found that about 13.1% of the total surgical supply cost was wasted [5]. Other
86
work has demonstrated that surgeons are often unaware of the cost of the equipment they
87
use on a regular basis [6]. Simply informing surgeons of the cost of instruments can
88
decrease the cost of procedures, including hysterectomy [7, 8]. Others have focused on
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the utilization of surgical instruments [7, 9, 10, 11]. Instruments alone may account
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for around 50% of the cost of a case [12]. There are studies from other surgical
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specialties that further suggest that as many as 80% of these instruments go unused
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during cases [13].
93
Cost in a healthcare setting is nearly impossible to accurately quantify. Prices of
94
equipment are rarely transparent and can be the result of lengthy negotiations with
95
suppliers. The costs to an institution beyond the initial purchase price of an instrument
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must take into consideration the operational cost of sterilizing, storing, packing,
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transporting, and restocking instruments. Quantifying the “each use” cost of reusable
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equipment is difficult. Often, when an instrument is purchased, the manufacturer
99
recommends a set number of sterilization cycles before it will need to be serviced or
100
replaced. By decreasing the number of times an instrument goes through the sterilization
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cycle unnecessarily, its life may be prolonged.
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We hypothesize that physician engagement in the maintenance of surgeon
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preference cards may increase operative room and supply chain efficiency. Our first
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specific aim in this study was to determine if a one-time, voluntary review by surgeons of
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the surgeon preference cards for their 5 most commonly performed procedures would
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decrease the cost of disposable and reuseable supplies used for a case. Our secondary aim
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was to determine if the above intervention decreased the rate of materials returned
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unopened to our case cart packing facility. Our tertiary aim was to better understand the
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process of surgeon preference card creation and maintenance at our institution and
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provide thoughtful qualitative commentary about this process to a wider audience of
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surgeons.
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Materials and Methods: All gynecologic surgeons in the Department of
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Obstetrics and Gynecology at Vanderbilt University Medical Center who had been in
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practice at VUMC for a calendar year prior to the start of the study were included. This
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totaled 21 surgeons; 11 generalists, 3 gynecologic oncologists, 4 female pelvic medicine
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and reconstructive surgery faculty, 2 minimally invasive gynecologic surgery faculty, and
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1 family planning specialist. For each surgeon’s five most frequently billed CPT codes
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during the prior calendar year were obtained from the VUMC billing department. Four of
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the surgeons billed less than 5 unique codes in the operating room during the prior year.
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These were academic generalists who spend the majority of their clinical time on Labor
124
and Delivery. This resulted in a list of 98 CPT codes. (Table 1). The surgeon preference
125
cards corresponding to each CPT and surgeon name were pulled from the VUMC
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computerized repository (proprietary software). Notably, this did not result in a 1:1 ratio
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of CPT codes to surgeon preference cards. It was observed that for 17 of the 98 CPT
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codes on the list, the surgeon listed did not have a surgeon preference card on file unique
129
to him or her for that procedure. The OR staff had been using another surgeon’s
130
preference card to prepare for those cases. Therefore, a total of 81 cards were distributed
131
to 21 surgeons for review. Options of “Keep,” “Discard,” or “Move” were offered for
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each item on the card. “Keep” meant to maintain the item “as is” on the card. “Discard”
133
removed the item from the card entirely. “Move” referred to an option to keep the item
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nearby the operating room, but it was not required to be placed in the OR, opened, or
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counted at the start of the case. Importantly, this also meant the item did not have to come
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pre-packaged into a case cart from our case cart facility. A limited supply of the item
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could be kept in the GYN OR core for use as needed. Once surgeons reviewed the cards,
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changes were approved or discarded by the gynecology perioperative charge nurse. The
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finance department at our institution evaluated case costs in the GYN operating suite for
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the calendar months following the changes (Jan-March 2016). These costs were
141
compared to the same three-month period the year prior (Jan-March 2015) to account for
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seasonal variation in case volume.
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Because VUMC’s instrument processing facility is located approximately 8 miles
144
from the medical center, there is considerable cost involved in the trucking of case carts
145
to the medical center. Prior work at our institution has estimated that the cost of one truck
146
to perform a trip is $41.23, roughly 1.3¢ per instrument [14]. One of the quality metrics
147
used by the facility is the number of instruments returned unused for each case. Even if
148
the instrument can be used again, VUMC pays a difficult-to-quantify cost for wear and
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tear on delivery trucks, employee hours used for restocking, and the complications in
150
inventory systems when instruments return. One can make the argument that each time
151
an instrument is not used, but ferried back and forth to the instrument processing facility,
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the cost of that instrument to the institution grows. In order to achieve our secondary aim,
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we examined the return rate reports to determine the number of instruments that were
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being ferried back from the GYN operating suites before and after our intervention.
155 156 157
This study was approved as a Quality Improvement initiative by the Vanderbilt University Medical Center Institutional Review Board. Results: Fourteen surgeons returned a total of 48 reviewed cards, 39 of which had
158
changes. There were 160 cases performed in January- March 2016 using the 39 surgeon
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preference cards that were modified in our intervention. The case distribution was as
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follows: 69 minimally invasive surgery cases, 58 female pelvic medicine and
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reconstructive surgery cases, 28 general gynecology cases, and 5 gynecologic oncology
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cases. These changes are discussed below according the category chosen for each item.
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Discarded items: A total of 109 disposable instruments or supplies were entirely
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removed from the 39 cards. The total cost of these items was $767.67. The range in
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price of these items was $0.15 to $289.00 and averaged $16 per card. The cost of
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disposable instruments removed from those cards for the 160 cases during our follow-up
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period was $2131.07, a measureable cost savings to our institution.
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Three instrument pans, vaginal instruments pan 1 and 2, and radical vulvectomy
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instrument pan were also completely removed from cards as they were deemed not
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necessary to the respective cases. Vaginal instrument pans 1 and 2 were removed from a
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single card and contain 145 instruments together. Previous work at our institution
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demonstrated that the cost to process 1 instrument, including fixed costs such as salaries
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for personnel and variable costs such as cleaning solutions, is about $3.19 [14]. That
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means each time this surgeon schedules a case using this modified surgeon preference
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card and CPT, the institution saves $462.55 on processing alone. From January 2016-
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March 2016, this preference card was used twice, making the savings on processing for
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this interval $925.10. The surgeon preference card from which the radical vulvectomy
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pan was removed was not used during the study period of January 2016-March 2016.
179 180
Keep available items: Twenty-two items were removed from the cards and placed
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into a “keep available” category. This means those items would not need to be packed,
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transported from the supply facility, routinely opened, and counted for each case. They
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would only be called for if necessary. Examples in this category ranged in size and price
184
from bipolar energy transducers, to mid-range items like suture passers, specimen bags,
185
and suction irrigation tubing, to small items like liquid adhesive and bandages. These
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items totaled $6,293.54. This is the category for which it was the most difficult to make a
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meaningful assessment. Inflation rates for cost of equipment were zero over this time
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period as had been previously stipulated in supply contracts. Our finance department
189
estimated that the cost savings for the 160 cases with modified surgeon preference cards
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during the three month study periodwould total $16,213.57. This was calculated using
191
the assumption that every item removed would have been opened and used. Not every
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item on the cards that was moved would have ordinarily been opened so this number is
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likely an overestimate. However, it has been noted with rotating scrub nurses unfamiliar
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with our practice, that sometimes every item on the card is opened. Prior to our
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intervention, twenty of these items would have been packed in a cart at a cost of roughly
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6.4¢ per instrument and ferried to the OR at a cost of roughly 1.3¢ per instrument had the
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preference card not been updated [14]. In January-March 2016, 126 item transports were
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reduced with a cost savings equaling a minimum of $9.70. Additionally, there are
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employee costs involved in circulating nurses unpacking the case carts that are decreased
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if fewer items arrive on the carts, but this is difficult to quantify.
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The biggest intervention was the removal of a $449 laparoscopic cutting forceps
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from a card for total laparoscopic hysterectomy that was then used 7 times in the Jan-
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March 2016 time period.
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If an instrument is brought to the OR and not used, there is still cost involved in
206
stocking and transporting that item. This is especially true at our facility which houses
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the majority of our case carts off-site. For the time period of January-March 2016, there
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were 160 cases performed in the GYN OR suite that used the preference cards identified
209
in our study. A total of 1536 items were returned to the case cart facility from the GYN
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OR suite during this time. This means that on average, for each operative case,
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approximately 9.6 instruments were being returned. We compared this to January-March
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2015. During this time there were 148 cases that used the preference cards identified in
213
our study with 1493 items returned which equalled an average of 10.1 instruments
214
returned per case.
215 216 217
Discussion:
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Our study evaluated a simple intervention in which a one-time review of 48
219
surgeon preference cards by fourteen surgeons resulted in concrete cost-savings. There
220
was a reduction of disposable equipment placed in the OR by an average $16 per card.
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There was also a reduction in turnover costs for instruments and in transport of
222
instruments.
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We discovered a number of interesting points during the process of this study.
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Generally, surgeons were unaware of many aspects of creating and maintaining their
225
preference cards. At our institution, there is likely a phenomenon of “Surgeon preference
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card creep” in which items are added to a card during a case “in the heat of the moment,”
227
but there is never a focused effort to review the entire card for items no longer desired.
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Sometimes when new physicians arrive, their new cards are copied from existing
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providers. New items are added, while some are never removed. It was an interesting
230
observation during this study that some items were being stocked, picked, and transported
231
that were never intentionally chosen to be in the room.
232
Several surgeons did not have surgeon preference cards for specific CPT codes
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(17 in total), and were unaware of this, suggesting that OR circulating nurses used
234
another surgeon’s card instead for some procedures. Secondly, in our system, many items
235
on the preference card were described in such a way that they were difficult to recognize.
236
Assistance of circulating nurses was required to “translate” as they were familiar with the
237
way the items were described. This difficulty lead to surgeons removing some items that
238
were required for a case, such as disposable light handles. Ultimately, each edited card
239
was given to the GYN OR charge nurse for review of changes before they were finalized.
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Creating a process of writing and maintaining clear, easy to read and edit surgeon’s
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preference cards may decrease barriers between surgeons and supply chains allowing for
242
more streamlined and effective systems.
243 244
Limitations of our study include the fact that it was conducted among one
245
specialty for a limited period of time. Another limitation is the aforementioned difficulty
246
of meaningfully calculating cost. Additionally, we cannot calculate the cost of surgeon
247
time in editing the cards. (Anecdotally, the authors observed that most cards were edited
248
during a one hour Grand Rounds presentation.) We cannot state conclusively that our
249
intervention lead to a decrease in the rate in returned instruments, but it is plausible to
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consider it may have at least contributed to the decrease in rate that was observed. Of
251
note, no items were added to the cards as a result of the study intervention.
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Conclusion: Reusable and disposable supplies are a large component of the
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variable costs incurred during surgical procedures. However, surgeons at our institution
255
are typically minimally involved or uninvolved in the creation and management of their
256
case cards, despite having the most immediate knowledge regarding needed instruments.
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It is notable in this age of value based health care that there is a gulf between the
258
processes of supply chain management and the individuals who have the most immediate
259
knowledge of what is required in the operating room. Increased transparency by
260
providing surgeons with information regarding the cost of instruments has already been
261
demonstrated to decrease cost [6,7]. Hospitals could further leverage surgeon experience
262
by engaging them in a process of creating and maintaining clear, easy to read surgeon
263
preference cards.
264 265 266
References:
267 268
1. Centers for Medicare and Medicaid Services. National Health Expenditure Data.
269
NHE Fact Sheet. https://www.cms.gov/research-statistics-data-and-
270
systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-
271
sheet.html. Accessed 12/14/2016.
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2. Squires D, Anderson C. U.S. health care from a global perspective: spending, use
273
f services, prices, and health in 13 countries. Issue Brief (Commonw Fund). 2015
274
Oct;15:1-15.
275 276 277
3. Chescheir, N Focus on Clinical Practice and Quality. Obstet Gynecol. 2017 Jan;129(1):1-2. 4. Centers for Medicare and Medicaid Services. National Health Expenditure Data.
278
Nation's health dollar - where it came from, where it
279
went. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
280
TrendsandReports/NationalHealthExpendData/Downloads/PieChartSourcesExpen
281
ditures2015.pdf. Accessed 3/8/2017.
282
5. Zygourakis CC, Yoon S, Valencia V, Boscardin C, Moriates C, Gonzales
283
R, Lawton MT. Operating room waste: disposable supply utilization in
284
neurosurgical procedures. J Neurosurg. 2017 Feb;126(2):620-625.
285
6. Jackson CR, Eavey RD, Francis DO. Surgeon Awareness of Operating Room
286
Supply Costs. Ann Otol Rhinol Laryngol. 2016 May;125(5):369-77.
287
7. Croft K, Mattingly PJ, Bosse P, Naumann RW. Physician Education on
288
Controllable Costs Significantly Reduces Cost of Laparoscopic Hysterectomy. J
289
Minim Invasive Gynecol. 2017 Jan 1;24(1):62-66.
290
8. Zygourakis CC, Valencia V, Moriates C, Boscardin CK, Catschegn S, Rajkomar
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A. Association Between Surgeon Scorecard Use and Operating Room Costs.
292
JAMA Surg. 2016 Dec 7.
293 294
9. Chin et al. “Reducing otolaryngology surgical inefficiency via assessment of tray redundancy.” J Otolaryngol Head Neck Surg. 2014 Dec 3;43(1):46.
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10. Guzman MJ, Gitelis ME, Linn JG, et al. A Model of Cost Reduction and
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Standardization: Improved Cost Savings While Maintaining the Quality of Care.
297
Dis Colon Rectum. 2015 Nov;58(11):1104-7.
298 299 300 301 302
11. van de Klundert J, Muls P, Schadd M. Optimizing sterilization logistics in hospitals. Health Care Manag Sci. 2008 Mar;11(1):23-33. 12. Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anesthesiol. 2009. Apr;22(2):242-8. 13. Stockert and Langerman. “Assessing the magnitude and costs of intraoperative
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inefficiencies attributable to surgical instrument trays.” J Am Coll Surg. 2014
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Oct;219(4):646-55.
305 306
14. Van Meter MM, Adam RA. Costs associated with instrument sterilization in gynecologic surgery. Am J Obstet Gynecol (2016). Nov; 215 (5): 652.
307 308
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Table 1: Most Commonly Billed CPT Codes Among Gynecological Surgeons No. of surgeons with procedure Procedure CPT Code among 5 most billed CPT codes Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without 58558 10 D&C Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra58611 8 abdominal surgery (not a separate procedure) Treatment of missed abortion, completed surgically; first trimester Laparoscopy with removal of adnexal structures Total laparoscopic hysterectomy <250g with or without removal of tube(s) with or without removal of ovary(s) Colposcopy of the cervix including upper/adjacent vagina with loop electrode conization of the cervix Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) Total abdominal hysterectomy with or without removal of tube(s) with or without removal of ovary(s) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Sling operation for stress incontinence (eg, fascia or synthetic) Revision (including removal) of prosthetic vaginal graft; vaginal approach Removal or revision of sling for stress incontinence (eg, fascia or synthetic) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Pelvic examination under anesthesia (other than local) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
59820
7
58661
5
58571
4
57461
4
58605
4
58563
4
58150
3
58565
3
57288
3
57295
2
57287
2
58671
2
57410
2
58662
2
Page 14 of 16
Harvey 15 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), 58180 with or without removal of ovary(s) Posterior colporrhaphy, repair of rectocele with or 57250 without perineorrhaphy3 Colpopexy, vaginal; extra-peritoneal approach 57282 (sacrospinous, iliococcygeus) Treatment of incomplete abortion, any trimester, 59812 completed surgically Cystourethroscopy (separate procedure) 52000, Vulvectomy simple; partial 56620 Vulvectomy, radical, partial 56630, Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) 57061, Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) 57267, Combined anteroposterior colporrhaphy; 57260, Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) 57283 Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach 57285, Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 57520, Laparoscopy, surgical, colpopexy (suspension of vaginal apex) 57425, Colposcopy of the entire vagina, with cervix if present;57420, Dilation of cervical canal, instrumental (separate procedure) 57800, Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix 57460 Endocervical curettage (not done as part of a dilation and curettage) 57505, Insertion of intrauterine device (IUD) 58300, Vaginal hysterectomy, for uterus 250 g or less 58260, Removal of intrauterine device (IUD) 58301, Endometrial sampling (biopsy) performed in conjunction with colposcopy 58110, Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) 58120, Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58542, Hysteroscopy, surgical; with removal of leiomyomata 58561, Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; 58550, Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58720, Curettage, postpartum 59160, Treatment of missed abortion, completed surgically; second trimester 59821
2 2 2 2 1
310 311
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Table 2: List of supplies removed from preference cards or moved off cards to a kept available status Instruments Disposables Reusables removed Supplies “kept changed: removed from card from card available” Suction tubing, arm 1 radiofrequency Specimen cup, noncradle, chlorhexidine controller for adherent sterile pad, gluconate skin prep, Impedance Controlled suture passer, suction chlorhexadine topical Endometrial Ablation tubing, 10mm antiseptic, drape System laparoscopic warmer, stat lock, specimen retrieval spatula, syringe 10cc, 4 instrument pans: bag, liquid adhesive, forced air patient Vaginal instruments bandages, 5mm warming unit, 16Fr pan I, vaginal laparoscopic cutting red rubber catheter, instruments pan II, forceps, laparoscopic spinal needle, bovie mini laparotomy pan, scissors insert, hair pencil, bovie pad, radical vulvectomy clipper head, sanitary pad, skin pan. laparoscopic marker, hair clipper advanced bipolar head, non-adherent forceps, laparoscopic sterile pad, suture ultrasonic and passer, 5mm advanced bipolar laparoscopic trocar, platform transducer. plastic bowl, hysteroscopy fluid management tubing, absorbable hemostat, foam donut, gloves, gown, safety needle, free Mayo needle, skin marker, half sheet. Total Cost:
$767.67
$6,293.54
314 315
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S1553-4650(17)30377-1 http://dx.doi.org/doi: 10.1016/j.jmig.2017.06.018 JMIG 3178
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
22-3-2017 7-6-2017 23-6-2017
Please cite this article as: Lara F B Harvey, Katherine A Smith, Howard Curlin, Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards, The Journal of Minimally Invasive Gynecology (2017), http://dx.doi.org/doi: 10.1016/j.jmig.2017.06.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Harvey 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Title: Physician engagement in improving operative supply chain efficiency through review of surgeon preference cards
39
and transporting of unnecessary supplies by improving the accuracy of surgeon
40
preference cards.
41
Study Design: Quality Improvement
42
Design Classification: Canadian Task Force Classification II-3
Authors: Lara F B HARVEY MD MPH1,3, Katherine A SMITH MD2, Howard CURLIN MD1 Division of Minimally Invasive Gynecology Department of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, TN 1
2Department
of Obstetrics and Gynecology Vanderbilt University Medical Center Nashville, TN 3Corresponding
author contact information: Lara Harvey MD, MPH Vanderbilt University Medical Center Department of Obstetrics and Gynecology 1161 21st Avenue South B-1100 Medical Center North Nashville, TN 37232-2519 Email: [email protected] Phone: (615) 343-7441 Fax: (615) 343-8881 The authors report no disclosures.
Precis: 30 words. A one-time surgeon review of preference cards at an academic medical center resulted in a decrease in the number of disposable and reusable instruments used in the operating room, potentially saving cost.
Abstract: Study Objective: To reduce operative costs involved in the purchase, packing,
Page 1 of 16
Harvey 2 43
Setting: Gynecologic surgery suite of an academic medical center
44
Participants: Twenty-one specialized and generalist gynecologic surgeons
45
Interventions: The preference cards of up to the five most frequently performed
46
procedures per surgeon were selected. A total of 81 cards were distributed to 21 surgeons
47
for review. Changes to the cards were communicated to the OR charge nurse and
48
finalized.
49
Measurements and Main Results: Fourteen surgeons returned a total of 48 reviewed
50
cards, 39 of which had changes. A total of 109 disposable supplies were removed from
51
these cards, totaling $767.67. The cost per card was reduced by $16 on average just for
52
disposables. Three reusable instrument trays were also eliminated from the cards, which
53
resulted in savings of about $925 in processing costs over three months. Twenty-two
54
items were requested by the surgeon to be available upon request; however, not routinely
55
placed in the room at the start each case, totaling $6,293.54. The rate of return of unused
56
instruments back to storage decreased after our intervention from 10.1 to 9.6 instruments
57
per case.
58
Conclusions: Surgeon preference cards serve as the basis for economic decision making
59
about the purchase, storing, packing and transporting operative instruments and supplies.
60
A one-time surgeon review of cards resulted in a decrease in the number of disposable
61
and reusable instruments that must be stocked, transported, counted in the OR, or
62
returned, potentially translating into cost savings. Surgeon involvement in preference
63
card management may reduce waste and provide ongoing cost savings.
64 65 66 67
Keywords: cost; quality; surgeon preference card; laparoscopy; surgery
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Text:
69
Introduction: Healthcare spending is expected to reach 20.1% of the United State’s GDP
70
by 2025 [1]. Despite this, Americans suffer poorer health and shorter lifespans than
71
people in other high-income countries [2]. Discussions about the need to improve cost-
72
effectiveness and quality of medical care grow more urgent in numerous venues. The
73
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the
74
Sustainable Growth Rate formula and the new Quality Payment Program is prompting a
75
renewed look at how to provide quality health care based on performance data in the
76
most cost-effective manner possible. The journal Obstetrics and Gynecology recently
77
introduced a new article type, Clinical Practice and Quality, addressing the imperative to
78
further quality improvement research in obstetrics and gynecology. The accompanying
79
editorial notes that meaningful venues for this important work have been lacking in
80
obstetrics and gynecology [3].
81 82
In 2015, 32% of healthcare spending went to hospital costs, of which operating
83
room costs are a part [4]. Decreasing supply waste in the operating room has been
84
pointed out as an avenue for improving efficiency. A recent study of neurosurgical cases
85
at Stanford found that about 13.1% of the total surgical supply cost was wasted [5]. Other
86
work has demonstrated that surgeons are often unaware of the cost of the equipment they
87
use on a regular basis [6]. Simply informing surgeons of the cost of instruments can
88
decrease the cost of procedures, including hysterectomy [7, 8]. Others have focused on
89
the utilization of surgical instruments [7, 9, 10, 11]. Instruments alone may account
90
for around 50% of the cost of a case [12]. There are studies from other surgical
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Harvey 4 91
specialties that further suggest that as many as 80% of these instruments go unused
92
during cases [13].
93
Cost in a healthcare setting is nearly impossible to accurately quantify. Prices of
94
equipment are rarely transparent and can be the result of lengthy negotiations with
95
suppliers. The costs to an institution beyond the initial purchase price of an instrument
96
must take into consideration the operational cost of sterilizing, storing, packing,
97
transporting, and restocking instruments. Quantifying the “each use” cost of reusable
98
equipment is difficult. Often, when an instrument is purchased, the manufacturer
99
recommends a set number of sterilization cycles before it will need to be serviced or
100
replaced. By decreasing the number of times an instrument goes through the sterilization
101
cycle unnecessarily, its life may be prolonged.
102
We hypothesize that physician engagement in the maintenance of surgeon
103
preference cards may increase operative room and supply chain efficiency. Our first
104
specific aim in this study was to determine if a one-time, voluntary review by surgeons of
105
the surgeon preference cards for their 5 most commonly performed procedures would
106
decrease the cost of disposable and reuseable supplies used for a case. Our secondary aim
107
was to determine if the above intervention decreased the rate of materials returned
108
unopened to our case cart packing facility. Our tertiary aim was to better understand the
109
process of surgeon preference card creation and maintenance at our institution and
110
provide thoughtful qualitative commentary about this process to a wider audience of
111
surgeons.
112 113
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Materials and Methods: All gynecologic surgeons in the Department of
116
Obstetrics and Gynecology at Vanderbilt University Medical Center who had been in
117
practice at VUMC for a calendar year prior to the start of the study were included. This
118
totaled 21 surgeons; 11 generalists, 3 gynecologic oncologists, 4 female pelvic medicine
119
and reconstructive surgery faculty, 2 minimally invasive gynecologic surgery faculty, and
120
1 family planning specialist. For each surgeon’s five most frequently billed CPT codes
121
during the prior calendar year were obtained from the VUMC billing department. Four of
122
the surgeons billed less than 5 unique codes in the operating room during the prior year.
123
These were academic generalists who spend the majority of their clinical time on Labor
124
and Delivery. This resulted in a list of 98 CPT codes. (Table 1). The surgeon preference
125
cards corresponding to each CPT and surgeon name were pulled from the VUMC
126
computerized repository (proprietary software). Notably, this did not result in a 1:1 ratio
127
of CPT codes to surgeon preference cards. It was observed that for 17 of the 98 CPT
128
codes on the list, the surgeon listed did not have a surgeon preference card on file unique
129
to him or her for that procedure. The OR staff had been using another surgeon’s
130
preference card to prepare for those cases. Therefore, a total of 81 cards were distributed
131
to 21 surgeons for review. Options of “Keep,” “Discard,” or “Move” were offered for
132
each item on the card. “Keep” meant to maintain the item “as is” on the card. “Discard”
133
removed the item from the card entirely. “Move” referred to an option to keep the item
134
nearby the operating room, but it was not required to be placed in the OR, opened, or
135
counted at the start of the case. Importantly, this also meant the item did not have to come
136
pre-packaged into a case cart from our case cart facility. A limited supply of the item
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could be kept in the GYN OR core for use as needed. Once surgeons reviewed the cards,
138
changes were approved or discarded by the gynecology perioperative charge nurse. The
139
finance department at our institution evaluated case costs in the GYN operating suite for
140
the calendar months following the changes (Jan-March 2016). These costs were
141
compared to the same three-month period the year prior (Jan-March 2015) to account for
142
seasonal variation in case volume.
143
Because VUMC’s instrument processing facility is located approximately 8 miles
144
from the medical center, there is considerable cost involved in the trucking of case carts
145
to the medical center. Prior work at our institution has estimated that the cost of one truck
146
to perform a trip is $41.23, roughly 1.3¢ per instrument [14]. One of the quality metrics
147
used by the facility is the number of instruments returned unused for each case. Even if
148
the instrument can be used again, VUMC pays a difficult-to-quantify cost for wear and
149
tear on delivery trucks, employee hours used for restocking, and the complications in
150
inventory systems when instruments return. One can make the argument that each time
151
an instrument is not used, but ferried back and forth to the instrument processing facility,
152
the cost of that instrument to the institution grows. In order to achieve our secondary aim,
153
we examined the return rate reports to determine the number of instruments that were
154
being ferried back from the GYN operating suites before and after our intervention.
155 156 157
This study was approved as a Quality Improvement initiative by the Vanderbilt University Medical Center Institutional Review Board. Results: Fourteen surgeons returned a total of 48 reviewed cards, 39 of which had
158
changes. There were 160 cases performed in January- March 2016 using the 39 surgeon
159
preference cards that were modified in our intervention. The case distribution was as
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follows: 69 minimally invasive surgery cases, 58 female pelvic medicine and
161
reconstructive surgery cases, 28 general gynecology cases, and 5 gynecologic oncology
162
cases. These changes are discussed below according the category chosen for each item.
163
Discarded items: A total of 109 disposable instruments or supplies were entirely
164
removed from the 39 cards. The total cost of these items was $767.67. The range in
165
price of these items was $0.15 to $289.00 and averaged $16 per card. The cost of
166
disposable instruments removed from those cards for the 160 cases during our follow-up
167
period was $2131.07, a measureable cost savings to our institution.
168
Three instrument pans, vaginal instruments pan 1 and 2, and radical vulvectomy
169
instrument pan were also completely removed from cards as they were deemed not
170
necessary to the respective cases. Vaginal instrument pans 1 and 2 were removed from a
171
single card and contain 145 instruments together. Previous work at our institution
172
demonstrated that the cost to process 1 instrument, including fixed costs such as salaries
173
for personnel and variable costs such as cleaning solutions, is about $3.19 [14]. That
174
means each time this surgeon schedules a case using this modified surgeon preference
175
card and CPT, the institution saves $462.55 on processing alone. From January 2016-
176
March 2016, this preference card was used twice, making the savings on processing for
177
this interval $925.10. The surgeon preference card from which the radical vulvectomy
178
pan was removed was not used during the study period of January 2016-March 2016.
179 180
Keep available items: Twenty-two items were removed from the cards and placed
181
into a “keep available” category. This means those items would not need to be packed,
182
transported from the supply facility, routinely opened, and counted for each case. They
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Harvey 8 183
would only be called for if necessary. Examples in this category ranged in size and price
184
from bipolar energy transducers, to mid-range items like suture passers, specimen bags,
185
and suction irrigation tubing, to small items like liquid adhesive and bandages. These
186
items totaled $6,293.54. This is the category for which it was the most difficult to make a
187
meaningful assessment. Inflation rates for cost of equipment were zero over this time
188
period as had been previously stipulated in supply contracts. Our finance department
189
estimated that the cost savings for the 160 cases with modified surgeon preference cards
190
during the three month study periodwould total $16,213.57. This was calculated using
191
the assumption that every item removed would have been opened and used. Not every
192
item on the cards that was moved would have ordinarily been opened so this number is
193
likely an overestimate. However, it has been noted with rotating scrub nurses unfamiliar
194
with our practice, that sometimes every item on the card is opened. Prior to our
195
intervention, twenty of these items would have been packed in a cart at a cost of roughly
196
6.4¢ per instrument and ferried to the OR at a cost of roughly 1.3¢ per instrument had the
197
preference card not been updated [14]. In January-March 2016, 126 item transports were
198
reduced with a cost savings equaling a minimum of $9.70. Additionally, there are
199
employee costs involved in circulating nurses unpacking the case carts that are decreased
200
if fewer items arrive on the carts, but this is difficult to quantify.
201
The biggest intervention was the removal of a $449 laparoscopic cutting forceps
202
from a card for total laparoscopic hysterectomy that was then used 7 times in the Jan-
203
March 2016 time period.
204
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Harvey 9 205
If an instrument is brought to the OR and not used, there is still cost involved in
206
stocking and transporting that item. This is especially true at our facility which houses
207
the majority of our case carts off-site. For the time period of January-March 2016, there
208
were 160 cases performed in the GYN OR suite that used the preference cards identified
209
in our study. A total of 1536 items were returned to the case cart facility from the GYN
210
OR suite during this time. This means that on average, for each operative case,
211
approximately 9.6 instruments were being returned. We compared this to January-March
212
2015. During this time there were 148 cases that used the preference cards identified in
213
our study with 1493 items returned which equalled an average of 10.1 instruments
214
returned per case.
215 216 217
Discussion:
218
Our study evaluated a simple intervention in which a one-time review of 48
219
surgeon preference cards by fourteen surgeons resulted in concrete cost-savings. There
220
was a reduction of disposable equipment placed in the OR by an average $16 per card.
221
There was also a reduction in turnover costs for instruments and in transport of
222
instruments.
223
We discovered a number of interesting points during the process of this study.
224
Generally, surgeons were unaware of many aspects of creating and maintaining their
225
preference cards. At our institution, there is likely a phenomenon of “Surgeon preference
226
card creep” in which items are added to a card during a case “in the heat of the moment,”
227
but there is never a focused effort to review the entire card for items no longer desired.
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Sometimes when new physicians arrive, their new cards are copied from existing
229
providers. New items are added, while some are never removed. It was an interesting
230
observation during this study that some items were being stocked, picked, and transported
231
that were never intentionally chosen to be in the room.
232
Several surgeons did not have surgeon preference cards for specific CPT codes
233
(17 in total), and were unaware of this, suggesting that OR circulating nurses used
234
another surgeon’s card instead for some procedures. Secondly, in our system, many items
235
on the preference card were described in such a way that they were difficult to recognize.
236
Assistance of circulating nurses was required to “translate” as they were familiar with the
237
way the items were described. This difficulty lead to surgeons removing some items that
238
were required for a case, such as disposable light handles. Ultimately, each edited card
239
was given to the GYN OR charge nurse for review of changes before they were finalized.
240
Creating a process of writing and maintaining clear, easy to read and edit surgeon’s
241
preference cards may decrease barriers between surgeons and supply chains allowing for
242
more streamlined and effective systems.
243 244
Limitations of our study include the fact that it was conducted among one
245
specialty for a limited period of time. Another limitation is the aforementioned difficulty
246
of meaningfully calculating cost. Additionally, we cannot calculate the cost of surgeon
247
time in editing the cards. (Anecdotally, the authors observed that most cards were edited
248
during a one hour Grand Rounds presentation.) We cannot state conclusively that our
249
intervention lead to a decrease in the rate in returned instruments, but it is plausible to
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consider it may have at least contributed to the decrease in rate that was observed. Of
251
note, no items were added to the cards as a result of the study intervention.
252 253
Conclusion: Reusable and disposable supplies are a large component of the
254
variable costs incurred during surgical procedures. However, surgeons at our institution
255
are typically minimally involved or uninvolved in the creation and management of their
256
case cards, despite having the most immediate knowledge regarding needed instruments.
257
It is notable in this age of value based health care that there is a gulf between the
258
processes of supply chain management and the individuals who have the most immediate
259
knowledge of what is required in the operating room. Increased transparency by
260
providing surgeons with information regarding the cost of instruments has already been
261
demonstrated to decrease cost [6,7]. Hospitals could further leverage surgeon experience
262
by engaging them in a process of creating and maintaining clear, easy to read surgeon
263
preference cards.
264 265 266
References:
267 268
1. Centers for Medicare and Medicaid Services. National Health Expenditure Data.
269
NHE Fact Sheet. https://www.cms.gov/research-statistics-data-and-
270
systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-
271
sheet.html. Accessed 12/14/2016.
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2. Squires D, Anderson C. U.S. health care from a global perspective: spending, use
273
f services, prices, and health in 13 countries. Issue Brief (Commonw Fund). 2015
274
Oct;15:1-15.
275 276 277
3. Chescheir, N Focus on Clinical Practice and Quality. Obstet Gynecol. 2017 Jan;129(1):1-2. 4. Centers for Medicare and Medicaid Services. National Health Expenditure Data.
278
Nation's health dollar - where it came from, where it
279
went. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
280
TrendsandReports/NationalHealthExpendData/Downloads/PieChartSourcesExpen
281
ditures2015.pdf. Accessed 3/8/2017.
282
5. Zygourakis CC, Yoon S, Valencia V, Boscardin C, Moriates C, Gonzales
283
R, Lawton MT. Operating room waste: disposable supply utilization in
284
neurosurgical procedures. J Neurosurg. 2017 Feb;126(2):620-625.
285
6. Jackson CR, Eavey RD, Francis DO. Surgeon Awareness of Operating Room
286
Supply Costs. Ann Otol Rhinol Laryngol. 2016 May;125(5):369-77.
287
7. Croft K, Mattingly PJ, Bosse P, Naumann RW. Physician Education on
288
Controllable Costs Significantly Reduces Cost of Laparoscopic Hysterectomy. J
289
Minim Invasive Gynecol. 2017 Jan 1;24(1):62-66.
290
8. Zygourakis CC, Valencia V, Moriates C, Boscardin CK, Catschegn S, Rajkomar
291
A. Association Between Surgeon Scorecard Use and Operating Room Costs.
292
JAMA Surg. 2016 Dec 7.
293 294
9. Chin et al. “Reducing otolaryngology surgical inefficiency via assessment of tray redundancy.” J Otolaryngol Head Neck Surg. 2014 Dec 3;43(1):46.
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10. Guzman MJ, Gitelis ME, Linn JG, et al. A Model of Cost Reduction and
296
Standardization: Improved Cost Savings While Maintaining the Quality of Care.
297
Dis Colon Rectum. 2015 Nov;58(11):1104-7.
298 299 300 301 302
11. van de Klundert J, Muls P, Schadd M. Optimizing sterilization logistics in hospitals. Health Care Manag Sci. 2008 Mar;11(1):23-33. 12. Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anesthesiol. 2009. Apr;22(2):242-8. 13. Stockert and Langerman. “Assessing the magnitude and costs of intraoperative
303
inefficiencies attributable to surgical instrument trays.” J Am Coll Surg. 2014
304
Oct;219(4):646-55.
305 306
14. Van Meter MM, Adam RA. Costs associated with instrument sterilization in gynecologic surgery. Am J Obstet Gynecol (2016). Nov; 215 (5): 652.
307 308
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Table 1: Most Commonly Billed CPT Codes Among Gynecological Surgeons No. of surgeons with procedure Procedure CPT Code among 5 most billed CPT codes Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without 58558 10 D&C Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra58611 8 abdominal surgery (not a separate procedure) Treatment of missed abortion, completed surgically; first trimester Laparoscopy with removal of adnexal structures Total laparoscopic hysterectomy <250g with or without removal of tube(s) with or without removal of ovary(s) Colposcopy of the cervix including upper/adjacent vagina with loop electrode conization of the cervix Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) Total abdominal hysterectomy with or without removal of tube(s) with or without removal of ovary(s) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Sling operation for stress incontinence (eg, fascia or synthetic) Revision (including removal) of prosthetic vaginal graft; vaginal approach Removal or revision of sling for stress incontinence (eg, fascia or synthetic) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Pelvic examination under anesthesia (other than local) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
59820
7
58661
5
58571
4
57461
4
58605
4
58563
4
58150
3
58565
3
57288
3
57295
2
57287
2
58671
2
57410
2
58662
2
Page 14 of 16
Harvey 15 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), 58180 with or without removal of ovary(s) Posterior colporrhaphy, repair of rectocele with or 57250 without perineorrhaphy3 Colpopexy, vaginal; extra-peritoneal approach 57282 (sacrospinous, iliococcygeus) Treatment of incomplete abortion, any trimester, 59812 completed surgically Cystourethroscopy (separate procedure) 52000, Vulvectomy simple; partial 56620 Vulvectomy, radical, partial 56630, Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) 57061, Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) 57267, Combined anteroposterior colporrhaphy; 57260, Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) 57283 Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach 57285, Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 57520, Laparoscopy, surgical, colpopexy (suspension of vaginal apex) 57425, Colposcopy of the entire vagina, with cervix if present;57420, Dilation of cervical canal, instrumental (separate procedure) 57800, Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix 57460 Endocervical curettage (not done as part of a dilation and curettage) 57505, Insertion of intrauterine device (IUD) 58300, Vaginal hysterectomy, for uterus 250 g or less 58260, Removal of intrauterine device (IUD) 58301, Endometrial sampling (biopsy) performed in conjunction with colposcopy 58110, Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) 58120, Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58542, Hysteroscopy, surgical; with removal of leiomyomata 58561, Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; 58550, Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58720, Curettage, postpartum 59160, Treatment of missed abortion, completed surgically; second trimester 59821
2 2 2 2 1
310 311
Page 15 of 16
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Table 2: List of supplies removed from preference cards or moved off cards to a kept available status Instruments Disposables Reusables removed Supplies “kept changed: removed from card from card available” Suction tubing, arm 1 radiofrequency Specimen cup, noncradle, chlorhexidine controller for adherent sterile pad, gluconate skin prep, Impedance Controlled suture passer, suction chlorhexadine topical Endometrial Ablation tubing, 10mm antiseptic, drape System laparoscopic warmer, stat lock, specimen retrieval spatula, syringe 10cc, 4 instrument pans: bag, liquid adhesive, forced air patient Vaginal instruments bandages, 5mm warming unit, 16Fr pan I, vaginal laparoscopic cutting red rubber catheter, instruments pan II, forceps, laparoscopic spinal needle, bovie mini laparotomy pan, scissors insert, hair pencil, bovie pad, radical vulvectomy clipper head, sanitary pad, skin pan. laparoscopic marker, hair clipper advanced bipolar head, non-adherent forceps, laparoscopic sterile pad, suture ultrasonic and passer, 5mm advanced bipolar laparoscopic trocar, platform transducer. plastic bowl, hysteroscopy fluid management tubing, absorbable hemostat, foam donut, gloves, gown, safety needle, free Mayo needle, skin marker, half sheet. Total Cost:
$767.67
$6,293.54
314 315
Page 16 of 16