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Hospital Play #3 – Shrinking Tray Content & Size

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July 11, 2018

There are multiple forms of waste in the OR. Every time an instrument pan is opened, all the instruments need to be reprocessed with the associated wear and tear, sterilization, and service delay. The costs associated with unnecessary instrument provision and unwrapping are significant, as indicated by the studies of our Chief Medical Officer and co-founder Dr. Alexander Langerman. ExplORer can be used by surgical teams in identifying opportunities to lean out trays, resulting in fewer wasted instruments, saving your OR time and money. In this post, we’ll explore the issue of OR waste and how ExplORer can help close the gap for tray management quality.


How big is the problem?

It is estimated that ORs account for a third of the waste generated by hospitals. Smith and Nephew [vi] conducted a study in 2015 that outlined 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. For a five surgeon practice group performing 1,250 surgeries per year, this represents a cost of $105,000 to $178,500 per year.

In Dr. Langerman’s 2014 study, 237 trays across 49 procedures in  four specialties were examined at a single large academic medical center in Chicago. [iii] Average instrument usage rates across each of these specialties was just 20 percent at most. The problems of oversized trays don’t stop there, since the number of instruments on a tray is directly correlated with the number of missing or broken instruments. [ii]


How does this translate into cost?

Dr. Langerman showed that the total processing cost for a single instrument is a minimum of $0.51* and can rise even higher depending on the specialty. Cardinal Health material distributor conducted a study in which surgeons looked at a visual comparison of needed versus excess instruments in their procedures. As a result, overall spending was reduced from $1,100,000 to $940,000, with the number of single sterile picks declining from 44,000 to 16,000, a 64 percent reduction in picks. [i] Other studies have shown that trays with fewer instruments maintain cost efficiency and patient safety [iv] and have no impact on operative time. [iii]


Is there a potential impact on patient quality of care?

Studies have shown trays with fewer instruments maintain cost efficiency and patient safety [iv] without impact on operative time. [iii] In fact, too many instruments can be problematic with teams focusing on instruments rather than patient safety.


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

From our experience, there are three reasons why surgical trays remain sub-optimized:

First, the systems utilized in the OR don’t support the maintenance of surgeon-specific trays. The problem starts with the EMR’s preference cards. These itemize excessive amounts of equipment with little regard for the surgical work to be performed. Furthermore, EMR systems have limited analytical capabilities and cannot highlight unused items on trays or signal tray reduction needs. This problem is exponentiated when trays are built using multiple surgeon’s preference cards.

Second, the surgical team doesn’t maintain a categorization scheme that enables them to lean out trays, 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. Thus, instruments used in emergencies and contingencies end up co-mingled with instruments that are always used.

Lastly, tray resizing initiatives fail because surgeons rarely see a detailed analysis of the instrument variability, or cost and operative data. Without enabling technology, creating these analyses is a unsustainable costly manual exercise. So, if analyses get done at all, it is executed so infrequently that corrective action can’t be executed.


What’s needed to close these gaps?

A new tool is required to identify these opportunities. ExplORer tracks step-by-step case progression, including the frequency of instruments used in each step and which instruments remain unused. This data can be analyzed by type of procedure, surgeon, surgical team, or practice groups to identify opportunities to standardize instruments. ExplORer collects and tracks requests to adjust instrument sets ensuring that changes don’t get lost and are analyzed for replication across other surgeons’ procedures. Finally, ExplORer can share data with EMRs and supply chain systems, closing the loop and ensuring that all players are up to speed on what is needed for surgery cases.

For example, we have enabled a reduction in tray size for an ENT surgeon from 150 instruments to 20. 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 for one procedure. At scale, in the average community hospital with 5,000 procedures, a saving of at least $100/procedure an improvement by over half a million dollars!

ExplORer Surgical is the digital workflow software solution for your OR to shrink tray content and save money. If you and your colleagues are working to reduce tray size, we’d like to help. To learn more about ExplORer, please contact us at and visit us online here.


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.


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

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

[iii] 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 unquantifiable, are not accounted for in the study.

[iv] 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.

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

[vi] 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).

[vii] 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.

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