The struggle to stay afloat: inattention to surgical material frugality in the hospital setting
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BACKGROUND: In much of the world’s eyes, the United States of America has been known as a place of hope, opportunity, freedom, wealth, and excellence. It is the place where if one works hard, they can achieve the so-called “American Dream”. This country has much to be proud of and lauded for, however with significant financial capital, power, and greed comes superfluity, complacency and a prodigal nature. Healthcare is among the most sizable and profitable industries in the world which functions to provide the world’s people with medical aid. As the global population increases over time, so does the number of patients. The United States are also part of this complex equation with a 13% population increase within the last 20 years (U.S. Census Bureau, 2017). Although technological advances have helped in this endeavor, medical waste has complimentarily increased alongside the sheer volume of patients. The rate at which hospitals dispose of medical materials daily is becoming unsustainable. Much of it comes from operating rooms. As time goes on and medicine keeps progressing, surgeons and healthcare workers are expected to do more with less. For healthcare workers in third world countries this is magnified because they have less financial capital, access to innovative medical technologies, and basic healthcare resources. Performing surgeries and saving lives under these circumstances make it critically important to be as efficient, with the surgical materials, as possible because they cannot afford to replenish the supplies like first world countries can. If countries with less means can perform surgeries safely and accurately, without cutting corners, while minding their disposable material usage rate, developed countries should be able to adopt that same ideal to improve their efficiency and sustainability rates in the operating room too. If frugality was on the minds of the surgeons, nurses, and hospital administration alike, significant cost reductions and a healthier environment may be seen sooner. With healthcare at a premium due to increases in hospital administration, pharmaceuticals, and insurance costs, hospitals and patients themselves are being hit hard. When times get hard, attention to detail becomes paramount, efficiency becomes priority, self-reflection becomes essential. Many hospitals in America have the luxury to spend copious amounts of money on a myriad of resources to ensure that patients get quality care, but this is not the case in many foreign countries. The first question that should be asked is how can hospitals maintain quality care while reducing expenditure costs? In other words, can they be more efficient with what they already have? If so, where, what department, and how? An immense issue that plagues hospitals and increases costs for the patients is unnecessary wastefulness. Waste occurs in all areas of the hospital including the emergency room, pre- and post-operation surgical suites, outpatient exam rooms, pharmacies and more, but one is particularly wasteful despite being the most profitable – the operating room. Operating rooms receive a great portion of surgical supplies, as they should, however, many surgical room attendants such as surgeons, nurses, technicians, and turnover staff may take their access to and often unnecessary excessive use of surgical materials for granted. A great way to lower cost expenditure, maintain excellent outcomes, and reduce waste is to be mindful of what is actually needed instead of opening sterile materials or instruments that have a high likelihood of not being used. OBJECTIVE: To monitor the amount of disposable surgical items that were opened and remained unused at the operating room table at the end of the surgical case and to estimate the cost of these items. Second, to determine if the relative amount and cost of these materials has increased, decreased, or remained the same between cases in 2014 and 2018. The third objective is to determine what feasible options exist that could aid in the reduction of overall waste in the operating room looking into the future. RESEARCH METHODS: This clinical research conducted was a prospective observational study. Based on data from the literature and a pivot survey, a power analysis determined that 50 would be an adequate number of cases to represent the current practices in the operating room. The same evaluator performed all observations and data were recorded. The observations made and data acquired occurred in the operating rooms of a hospital in the New England region. The observations and data occurred over a 5-week period in 2014 and a subsequent 5-week period in 2018. The evaluator was observing the operating rooms in person over a continuous period of 5 weeks, totaling 102 cases. The evaluator recorded each opened surgical materials during the case. At the end of each case, the evaluator recorded the items that were opened but not used, and therefore were disposed of without being used. The different items were grouped into the following categories: gloves, gauzes, covers, towels, wraps, sutures, plastic disposals, metal disposals, material items, and miscellaneous items. The same process was repeated at each case and the list of all non-used items was collected out of 51 cases in 2014. The total cost was estimated based on the cost per item. The same process was performed for 2018 cases. A comparison of the number of non-used items and their respective between 2014 and 2018 was performed. The evaluator also attempted to calculate the cost per unit based on the total cost of items per group and by dividing it per item number. In order to obtain an overall estimate of the annual cost of the non-used items, the evaluator estimated the number of items and cost based on an estimate of 10,000 cases performed annually at a major surgical center, and these data were projected to estimate the approximate cost per 10,000 cases. Discussions were had with surgeons, a clinical nurse manager, scrub nurses, and surgical technologists in an effort to hear their opinions of the current state of operating room waste and how they believe operating room material management can be improved in the future. Statistical analysis was performed with SPSS 24.0 (IBM, USA). Categorical data analysis was performed with Fisher exact test. Non-categorical data analysis was performed using ANOVA. Statistical significance was set at p<0.05. RESULTS: Our analysis found that the total number of wasted items for the 51 surgical cases in 2014 and the 51 surgical cases 2018 were 812 and 819 respectively. The total number of wasted items the evaluator was able to find pricing for were 719 for 2014 and 640 for 2018. The total cost of wasted items in 2014 and 2018 that the evaluator acquired pricing for equaled $1027.31 and $874.75 respectively. The average cost per item wasted in 2014 was $1.43 and the average cost per item wasted in 2018 was $1.37. The 2014 usable count for unused items per group are 279 gauzes, 129 plastics, 125 towels, 80 sutures, 59 metals, 47 gloves, 33 covers, 19 wraps, 14 plastics/materials, 13 miscellaneous (Graph 1). The 2014 total cost for unused items per group are $164.14 gauzes, $199.03 plastics, $99.23 towels, $164.35 sutures, $98.52 metals, $85.34 gloves, $68.29 covers, $33.34 wraps, $49.00 plastics/materials, and $18.01 miscellaneous (Graph 1). The 2018 usable count for unused items per group are 318 gauzes, 29 plastics, 129 towels, 24 sutures, 22 metals, 54 gloves, 27 covers, 22 wraps, 15 plastics/materials, and 0 miscellaneous (Graph 5). The 2018 total cost for unused items per group are $189.96 gauzes, $40.66 plastics, $158.67 towels, $140.83 sutures, $9.53 metals, $100.40 gloves, $81.16 covers, $88.44 wraps, $65.10 plastics/materials, and $0 miscellaneous (Graph 5). For the projected cost, we calculated an annual cost for the estimate of 10,000 cases per year $209,456 for 2014 and $178,360 for 2018 (Graphs 3, 4, 7, 8). The average costs per unit of wasted materials in 2014 were $3.50 plastics/materials, $3.09 miscellaneous, $2.70 sutures, $2.67 wraps, $2.37 covers, $1.86 gloves, $1.79 metals, $1.64 plastics, $1.23 towels, and $0.59 gauzes (Graph 2). The average costs per unit of wasted materials in 2018 were $4.34 plastics/materials, $0 miscellaneous, $5.87 sutures, $4.02 wraps, $3.01 covers, $1.86 gloves, $0.43 metals, $1.40 plastics, $1.23 towels, and $0.60 gauzes (Graph 6). For the total 2014 and 2018 wasted item types vs count, the only statistically significant difference was the sutures that went down from 80 wasted to 24 (Graph 9). For usable 2014 and 2018 wasted item types vs count, gauzes, plastics, towels, sutures, metals, and miscellaneous all had a statistical significance p-value of <0.05 (Graph 10). For 2014 and 2018 wasted item types vs cost, gauzes, plastics, towels, metals, wraps, plastics/materials, and miscellaneous all had a statistical significance p-value of <0.05 (Graph 11). CONCLUSIONS: The total counts of disposable materials wasted in 2014 and 2018 are very close. The total cost of those wasted materials was greater in 2014 than 2018, but not large enough to show it is not by chance. The projected annual savings were near $200,000. This money could have been reallocated for other important causes. There were some statistically significant material type groups and cost differences between 2014 and 2018, but not enough to show that a real change in behavior caused it. Based on previous publications, discussions with surgeons and nurses, as well as the evaluator’s own beliefs, there are several promising solutions to make meaningful impacts on the amount of unnecessary wastage that occurs in operating rooms and hospitals in general.