Play #1 – Reducing Disposables Waste in the OR
The Operating Room (OR) is typically the largest generator of revenue for the hospital as well as the largest cost center. The OR often accounts for over 40% of hospital expenses.
There are many potential targets for cost reduction in the surgical care cycle, but the most challenging has always been the “intraoperative” period – when the surgical procedure actually takes place – and where major losses occur due to wasted surgical supplies. We refer to these as “opened-but-unused items”: anything that is opened in the OR must be discarded or re-sterilized, so the unnecessary opening of supplies means increased costs and waste.
There are three types of supplies and tools used in the OR – implantable devices, sterilized instruments, and consumable/disposable surgical supplies. Varied physician preference for certain types of disposable supplies such as staplers, sutures, and devices create significant complexity to manage. The attending surgeon determines which items are used in any given procedure. However, the surgeon’s decisions or stated preferences are insufficient to thwart substantial amounts of waste in surgical procedures. In the face of rotating surgical techs and surgical nursing teams, we find that 85% of nurses over-prepare for surgical cases by opening extra items that are never used.
This over-preparation is understandable. Nurses and techs can face significant pressure from surgeons to “have everything ready,” and often feel they have fallen short of their duties if the item a surgeon asks for is not immediately available. Furthermore, there is no downside for over-preparation: with little ability for hospitals to track supplies that are opened but unused, this waste is an unrecognized cost that does not reflect on the surgical team but has a significant impact on the hospital’s expenses.
The fundamental problem is informational. Surgeons might know what tools they want, but rarely have insight into their preference cards. Nurses know that preference cards are often inaccurate. Knowledge about surgeon preferences and if-then scenarios reside in the minds of nurses and techs who have worked extensively with that surgeon, but this information is not easily shared individually or collectively, especially during a procedure.
Most troubling is that the very document that’s supposed to help with these problems, the preference card, is designed more for case cart creation and warehouse management than for working surgical teams. Preference cards provide little to no operative value, because they lack workflow information such as instrument use by stage and step of a procedure.
This informational gap is a huge problem – it accounts for billions of dollars of waste each year and deserves serious attention, particularly in the estimated nationwide $2B annual opportunity of opened-but-unused disposable supplies.
Our research and experience in the OR at more than 18 different institutions shows that the surgical team’s knowledge of the procedure to be performed is one of the most robust predictors of waste and inefficiency.  We specifically designed ExplORer to address this informational gap and inform surgical teams regarding what supplies are needed, which should be opened and ready (and when), and which should be held in reserve and only opened if needed.
By way of example, consider the following two case studies, which underscore the importance of using technology to close the knowledge gaps that drive waste and potentially impact outcomes.
Average Opportunity $200-300/Case
In a research study reviewing cases across general, neurosurgery and plastics surgery cases at one academic medical center, we noted that, on average, surgical teams wasted $210 per case in opened but unused supplies. This primarily occurred because team members did not have the requisite knowledge of how the surgeon wished to perform the case: preference card and operating notes were either inaccurate or inadequate for capturing the needs of the procedure. Additionally, there was a high degree of variability across surgeon’s procedures, making it difficult for nurses to readily predict the case’s needs. In the absence of intraoperative guidance, team members opted to grab supplies based on their own guesses and prior experience, even if these items weren’t on the preference card, to be sure there wouldn’t be anything missing for the case.
In an early study of ExplORer Surgical’s digital intraoperative workflow management solution applied in laparoscopic cholecystectomies, disposable waste was reduced by more than 95% by having a real-time information system available in the sterile field. Nurses and techs told us that the unambiguous, immediately available information took the guesswork out of room preparation and intraoperative supply management. Circulators and scrub nurses frequently comment: “Having ExplORer in the OR allows me to know exactly what instruments and supplies we will use and have confidence the room is set up right.”
Neuro Surgery Procedures Waste $968/Case
Similarly, researchers at UCSF tracked waste during neurosurgery procedures at their hospital and discovered that, on average, $968 of medical supplies are wasted per case, totaling $2.9 million per year for that institution. In addition to presenting surgeons with cost data on their procedures (an educational process found to reduce waste), UCSF has also begun to educate its surgical team members on the value of waste reduction and to encourage them to work collaboratively to identify exactly what is needed before each procedure.
Such collaboration is exciting but also reflects the results of a focused team effort. This effort may not be sustainable without technological support like ExplORer. “Teamwork” efforts are commonplace in hospitals, and typically wax and wane based on the quality improvement effort-du-jour. With ExplORer, teamwork can be enhanced by motivating nurses, techs, and surgeons to focus on cost reduction and surgical efficiency together. This collaboration happens three ways:
First, in hospitals, greater procedural knowledge, particularly of surgical steps, instruments, and supplies utilized by step is required to eliminate unintentionally wasteful behavior. With the help of ExplORer, team members can acquire procedural knowledge before the day of surgery, or if necessary, real-time during a case, eliminating unintentional opening of supplies and time-consuming and distracting departures from the OR to hunt for supplies that team members anticipate might be needed for a procedure.
Second, using ExplORer to first map surgical procedures and then detail instrument utilization based on the surgical work to be performed, ExplORer provides the “lean” context necessary to review instrument and supply needs critically, as well as to identify procedural variances between surgeons and differences in supplies.
Third, ExplORer can be used during or at the end of procedures, to track supplies, identify opened and unused items, determine items that enter the OR that are not on the preference card as well as those used in contingencies.
If you and your colleagues are working to reduce disposable waste in your OR, we’d like to help. To learn more about ExplORer Surgical, and how we might help, please contact us at info@ExplORersurgical.com and visit us online here.
Posted by: Alex Langerman, CMO and MD, and Jennifer Fried, CEO
About ExplORer Surgical
ExplORer Surgical is an interactive surgical playbook that reduces disruptions and wasted disposables by improving surgical team communication. ExplORer Surgical also provides real-time performance and scheduling data to OR administrators to enhance quality of care and efficiency. Surgical teams use the software to coordinate their activities while managing their tools and supplies in a way never before possible. The result is optimal teamwork, increased efficiency, and high performance.
 Guerriero F. Guido R. Operational research in the management of the operating room theatre. Healthcare Manag Sci 2011.
 “Clinical Supply Documentation in the OR, What’s the Problem?”, Presented by: Karen Conway
Executive Director of Industry Relations, GHX.
 Langerman, Alex et al at ExplORer Surgical, 2015-2016.
 Castelluci, Maria. Hospital ORs Waste Millions a Year in Disposable Medical Supplies, Modernhealthcare, September 2016.