As the cost of the Canadian healthcare system continues to balloon, new and innovative ways to improve operating room efficiency are continually being sought. Anecdotally, it was noted that many instruments were present but not being used on surgical trays that were opened routinely, and indeed after analysis over 70% of our instruments met criteria for being superfluous to the majority of procedures. It is important to remember that this number looks at only a small number of procedures within the relatively small specialty of Otolaryngology- Head and Neck Surgery. Our novel data strongly suggests that if this type of analysis were to be expanded to a wider array of procedures done by our specialty, to say nothing of other surgical specialties who undoubtedly have the same high level of instrument redundancy, efficiency improvement to the hospital would be substantial.
A question that remains after the trays are reduced is what to do with the removed instruments. Some are completely redundant, while others are potentially needed rarely. One option would be to individually wrap each instrument, and open it only when the specific instrument is requested. A second option would be to wrap the instruments in “groups”, similar to the frontal sinus instruments. In these cases, if the surgeon feels that a particular instrument or set of instruments would be warranted, they could request them and the instruments would then be opened. Given that we based our tray reductions on a “20% usage rule”, as previously described, we believe that these instruments would be infrequently opened and that this would be a reasonable solution that has worked very well for both the sphenoid and frontal instruments at our site (usage rates of 50 and 51.67% respectively). Importantly, once implemented, instrument utilization would be monitored and any instrument that is more frequently requested can simply be added back onto the surgical tray.
This study has several limitations. The cost estimates are relevant in economic terms. Tray building time measurements were obtained from London-based hospitals and may be different at other sites in Ontario or Canada; hence the results may not be seamlessly generalizable, although the basic concept of the study likely is. Potential time-savings during the decontamination process were not incorporated due to a lack of data; however, decontamination times are unmeasured because decontamination occurs in batches and is not considered a significant cost driver in the CPD department.
There are several future directions to study. Other efficiencies could also be anticipated such as shorter set-up times for nurses between cases and smoother flow within surgical cases (as nurses will have an easier time locating the requested instrument). There would also be a significant reduction in the cost of purchasing the surgical instruments to create new trays or replace existing instruments. Both of these concepts pose questions that can be examined with future research in this area. Furthermore, a formal cost analysis should be performed both with our data and that of other services. From an environmental perspective, much has been written about the amount of waste produced from the operating theatre [3],[4]. The simple act of shrinking the contents of trays, and combining multiple trays into fewer trays, would immediately reduce the waste produced from the tray wrappings. As well, smaller, more efficient trays should allow for savings in energy, water, and reagent when running the washer. These are all unexplored areas of efficiency improvement that while small individually would over time produce incremental and measurable financial improvements in the Operating Room, and remain as areas for further study. Lastly, there is also the potential for intangible benefits that come with the anticipated faster and simpler set-up in the OR. These benefits include reduced stress in the OR, greater time for surgical learning, and improved flow of surgical cases, particularly when searching for an instrument in high-stress situations. These are all areas of future investigation.