Two years ago, I wanted to reduce the amount of material being thrown into disposal bins at the end of operative procedures at my institution’s hospital. After I spoke with all the parties involved—supply chain managers, medical device company representatives, clinic and operating room nurses, surgeons, perioperative services staff, and billing office staff—and mapped out how supplies were acquired, used, and subsequently disposed of, I thought I had found the source of the problem. The tools selected before any given surgical procedure were determined based on what the surgeon preferred to use, and the list was only updated if the surgeon had specific requests. As a result, instruments were being brought, opened in preparation for a case, and then left unused. Any instruments that were exposed in the operating room are no longer sterile and are thrown out. Eliminating opened and unused items from the waste stream by updating surgeon preference lists could save money for the hospital and decrease medical waste.

I was inspired to take on the project by a strong sense that the medical community was out of touch with the impact of hospital waste on the health of communities and ecosystems. Medicine’s first commandment, to do no harm, is readily applied to patients in hospital beds, but it wasn’t being applied to the land and air surrounding landfills and to reprocessing plants. The most up-to-date data on hospital waste is from the 1990s, when U.S. hospitals produced more than 2.3 million tons of waste—or an average of 26 pounds of waste per staffed bed each day—every year. Twenty to 30 percent of this waste came from operating rooms. I wanted to hold our hospital accountable for contributing to this profound littering; I wanted to make the waste apparent and offer hospital employees the opportunity to decrease these numbers.

 

Choosing Disposable Surgical Tools

If you were to look into Central Sterile Processing (CSP) at our institution, you wouldn’t be surprised by the amount of waste generated in Operating Rooms. CSP is where supplies are stored and where reusable items come for reprocessing at the end of a case—and it’s massive. Rows of packaged goods and trays line the walls and create aisles in a room about the size of four tennis courts. And the space doesn’t even house all disposables items, most of which are stored on in or just outside of operating rooms for convenience.

More impressive than CSP’s size is the number of different supplies stored there. Surgeons have preferences for the tools they like (based on how they were trained or what medical device representative suggested), and the hospital tends to accommodate their requests. Basic research is conducted by the sourcing department on the cost and effectiveness of each tool, and then the tools are purchased for use in the hospital. Surgeons may use different instruments for the same procedure, which limits the hospital’s bargaining power when establishing prices with medical device companies. Staff are often confused as to what’s needed if they don’t know how the tools function.

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Scheduling a Procedure

The surgeon develops an intention and a vision of the execution of a procedure once a case is scheduled. The surgeon communicates the nature of the procedure to the clinic nurse or scheduler by giving the name of the procedure, which is then entered into the scheduling system. The system then prints a corresponding set of instructions and required tools is printed out in preparation for the case.

This system works when the surgeon’s intention is listed in the computer system. But sometimes the intention is a variation from the norm based on differences in patient factors, and surgeon nomenclature often varies from the nomenclature in the computer system. The result is an inaccurate name being applied to the case, and subsequently, incorrect supplies being prepared for the case.

Teams in the OR

At our institution, the list of supplies given for each procedure is specific to the surgeon and only updated occasionally (with some difficulty). When a surgeon is scheduled to perform a case for which there isn’t an associated list, a generic “base card” is automatically uploaded in its place. These cards often vary considerably from what the surgeon expects.

For hospital staff with little experience working with a particular surgeon, these lists are the only source of information about preferences; if the list is off, the wrong supplies will show up. If additional items are needed during a procedure, selecting the item the surgeon wants (often with limited information) offers an additional challenge that may lead to more supplies being opened than necessary. For departments where more teams have to work together, OR nurses know from experience what the surgeon uses and can accurately pick what is needed, before and during the procedure, with minimal help from the surgeon or a list.

Regardless, there is still a pervasive philosophy of “better safe than sorry” that applies to acquiring supplies preoperatively: tools are bought in excess to avoid not having the supplies needed.

 

Data Collection and Feedback

Data is not collected on the tools actually used in the operating room—information that would greatly improve accuracy in acquiring supplies, regardless of who is assigned to a case. Surgeons could see how their usage compared to that of their colleagues. Instead, we are relying on first-hand witness accounts rather than objective measurement tools of what tends to be used to dictate what is brought going forward.

 

In Context

But contributors to medical waste—medical supply companies, sourcing department employees, surgeons, nurses, schedulers, and operating room staff—bring with them possible solutions. Hospitals could buy more reusable supplies and track how supplies are used. Surgeons could standardize the tools used for given procedures. Hospitals could instruct their staff to keep items in their package prior to use. Surgeons could provide schedulers with more information regarding their intended approach and desired instrumentation for a procedure (research I’m working on at our institution now).

Much is also being done to decrease medical waste across the country, largely due to financial incentives. Medical device companies are reprocessing disposable surgical tools —cleaning, recalibrating, repackaging, and resterilizing—before selling them back to hospitals at a discounted price. Nonprofits like Practice Greenhealth are working to decrease the environmental impact of healthcare facilities through initiatives like Greening the OR, which finds and shares information about sustainable practices in the operating room. Unused instruments are donated to charities abroad. And there is more to come.

There are many layers and component parts contributing to the tons of waste being brought to landfills every year from hospitals and elsewhere. In the hospital, addressing waste involves applying an understanding of finance, workflow, communication, data analytics, and technology to supply acquisition, use, and disposal. This work is currently being undertaken at our institution by the Operative Performance Research Institute, an interdisciplinary team of hospital staff, doctors, nurses, and students of medicine, business, and design dedicated to maximizing efficiency and cost-effectiveness in the operating room. Together, we are making waste visible, measurable, and relevant—to the health of the hospital, the patient, and the natural world.


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Image Credit: Thomas Quine via flickr