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Play #3 – Shrinking Tray Content/Size


There are multiple forms of waste in the OR. We’ve previously discussed the importance of preventing disposable waste to drive down surgical costs. However, preventing “open-but-unused” items in the OR is not just limited to disposables. Every time an instrument pan is opened, every single instrument contained in those sets be reprocessed, with the associated material handling, sterilization, wear and tear, and service delay. Costs associated with the unnecessary instrument provision and unwrapping are significant, as indicated by the studies of our co-founder and Chief Medical Officer Dr. Alexander Langerman and others noted below.

In this post, we’ll explore just how big of a problem this is, what it costs, the impact of tray management on quality, why this problem persists, and what’s needed to close the gap.

How big is the problem?

Many studies have been performed identifying the amount of hospital waste generated in the OR. Generally, its estimated that ORs account for a third of the waste generated – from a variety of sources – by hospitals. While it’s unclear exactly what portion of this waste instruments account for, the costs are high. Smith and Nephew conducted a study in 2015 that found the average processing cost of unused instruments for four different procedural areas ranged from $84 to $143, with ENT at the low end and Neuro/Spine at the high end.[i] For a five surgeon practice group performing 1,250 surgeries per year, this represents a cost of $105,000 to $178,500 per year.

Dr. Langerman’s 2014 study illustrates what drives these costs. In his study 237 trays across 49 procedures in 4 specialties were examined at a single large academic medical center in Chicago.[ii] Average instrument use rates across each of these specialties was at maximum of just more than 20%. In Otolaryngology, it was 13.0% (±4.2%), in Plastic Surgery 15.5% (±2.9%), in Bariatric Surgery 12.2% (±5.0%) and in Neurosurgery 21.9%(±1.7%).

Interestingly, another study found that the problems of over-sized trays don’t stop there; the number of instruments on a tray is directly correlated with the number of missing or broken instruments.[iii]

How does this translate into cost?

Dr. Langerman showed that the total processing cost for a single instrument can run at least $0.51* with additional studies showing that this cost can rise even higher depending upon the specialty.

In a study conducted by material distributor Cardinal in which surgeons were made to look at a visual comparison of needed instruments to excess in their procedures, overall spending was reduced from $1,100,000 to $940,000, with the number of single sterile picks declining from 44,000 all the way to 16,000, a 64% reduction in picks.[iv]

In a different study on surgical instrument costs,[v] Dr. Langerman showed that by removing 80 unused instruments from a single type of tray which is opened 10x/week for 50 weeks, the studied institution could save $4,000 to $20,400/year by optimizing a single tray. This is particularly profound given the institution “processes approximately 100,000 trays and over 2.6 million instruments per year.”

Is there a potential impact on patient quality of care?

Other studies have shown that trays with fewer instruments maintain cost efficiency and patient safety[vi] and have no impact on operative time.[vii] In fact, having too many instruments can be its own cognitive burden: dedicating excessive time to instrument counts is distracting to the team and can be detrimental to patient care.

If the potential savings are so high, why does this problem persist?

Based on our experience, there are three reasons that surgical trays remain sub-optimized.

First, the systems used by the surgical team and supply chain frequently don’t support the maintenance of surgeon-by-surgeon trays. The problem frequently starts with the EMR’s preference cards which are profligate itemizers of excessive amounts of equipment with little or no regard for the surgical work to be performed. Similarly, EMR systems have limited ability to analyze utilization patterns and highlight unused items on trays or signal tray reduction needs when items are removed from preference cards. This problem is compounded when central sterile builds its trays using multiple surgeon’s preference cards and creates the “do everything tray” without any visibility into what is actually used in a case.

Second, the surgical team and supply chain team don’t maintain a categorization scheme that enables them to lean out trays, reduce materials handling, and eliminate re-sterilization and repackaging. Instruments on a tray fall into three categories of use:

  1. Instruments that are always used per the surgeon’s preference,
  2. Instruments that are used in emergencies.
  3. Instruments that are used for operative contingencies,

Unfortunately, instruments are frequently not segregated and marked according to use. As a result, instruments used in emergencies and contingencies end up co-mingled with instruments that are always used when they could be sequestered and remain wrapped and unopened until they are needed either in auxiliary trays or peel packs.

Third, tray resizing initiatives fail because surgeons rarely see a detailed analysis of the variability of instrument use for specific procedures, or cost and operative data that corroborate the need for a reduction in tray sizes and/or standardization of instruments. Without enabling technology, creating these analyses is a costly manual exercise that is unsustainable. So, if analyses get done at all, they are done so infrequently that corrective action can’t be sustained.

What’s needed to close these gaps?

A new set of tools, like ExplORer, that are used in the surgical workflow are required to identify opportunities to lean out trays and lock in these adjustments.

ExplORer tracks step-by-step case progression, including what instruments are provided, the frequency of instruments used across each step of a case, and which instruments  remain unused. This data can be analyzed by type of procedure, by surgeon, by surgical team, or by practice group to identify opportunities to standardize instruments as well as reduce tray size. ExplORer collects and tracks requests to adjust instrument sets ensuring that changes do not get lost and are analyzed for replication across other surgeons’ procedures. Finally, Explorer can share data with EMRs and supply chain systems if desired, closing the loop and ensuring that all players are up to speed on what is needed for surgery cases.

For example, we have been able to identify and enable a reduction in tray size for an ENT surgeon from 150 instruments to 20, a change which created significant value.  Imagine if your instrument processing cost was $1 – 3 per instrument in the above scenario. The cost savings per case would be in the range of $130 – $390 per case. Cumulatively for one surgeon performing 200 cases per year, this could produce $26,000 to $78,000 in savings per year on just one procedure.

At scale, in the average community hospital with 5,000 procedures, a saving of upwards of at least $100/procedure improves the bottom line by over half a million dollars!

Posted by: Thomas G. Knight, Chief Operating Officer and Andy Rapoport, Chief of Staff

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.

Interested in learning more?

If you and your colleagues are working to reduce tray size, 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.

[i]  Hensell MG, Pins J. Virtual BackTable. Reducing Cost of On-boarding. Presented at the AORN Surgical Conference and Expo 2015.

[ii] Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219(4):646-55.

[iii] Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery 2006;139:159-173.

[iv] Champion, S. (2017, March 7). Optimization of Custom Procedure Trays [Webinar].

[v] Mhlaba JM, Stockert EW, Coronel M, Langerman AJ. Surgical instrumentation: the true cost of instrument trays and a potential strategy for optimization. J Hosp Adm. 2015;4(6).

[vi] Greenberg JA, Wylie B, Robinson JN. A pilot study to assess the adequacy of the Brigham 20 kit for cesarean delivery. Int J Gynaecol Obstet 2012;117:157-159.

[vii] Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of Lean Methodology for Improved Quality and Efficiency in Operating Room Instrument Availability. J Healthc Qual. 2015;37(5):277-86.

*This includes direct costs such as labor ($0.10) and depreciation ($0.02 to $0.18), indirect costs such as utilities ($0.09) and repair ($0.14). Other costs, both quantifiable and not quantifiable, are not accounted for in the study.



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