Perioperative and
Emergency Services Specialists

In the News

Part Two: Surgical Preference Lists and Case Carts

Below I describe who, what, where, when and why (not in that order) of building a procedure case cart.
Prior to a procedure, the preference lists discussed in last month’s newsletter, are pulled for the scheduled cases. All of the items on the list should be placed on a cart in an orderly manner so that the circulating nurse and the surgical technician can bring the supplies into the procedure room and open all of the supplies. At the end of the case, this same cart should be used for transporting either the left over supplies, or the dirty instruments to the appropriate area for further disposition.

There are 2 kinds of case carts:

  • Open carts do not confine and contain the items pre or post-operatively. This means that it is possible for someone in a hurry to find a supply on an already prepared cart and take it. Additionally, at the end of the case, it is difficult to confine and contain dirty instruments on an open cart. We frequently see hospitals not in compliance with this recommended practice from AORN. There are disposable plastic enclosure bags that can be used for this purpose and should be implemented if this is your current process.
  • Closed carts are typically made like a rolling cabinet with a door that closes and multiple shelves inside. There are a number of shapes and sizes available and they should be selected based on the types of cases performed at the facility, the available space for carts, the ability to clean the carts and the preference of the staff that use them. A seal can be place on them to identify if they have been opened, and they more easily confine and contain dirty instruments.

It is important to plan where these case carts will be built and stored prior to the procedure, transported and cleaned after the procedure, and stored until use again:

Prior to the procedure the cart may need to go to multiple locations to be filled properly. There are some departments that have a large center core where all supplies and instruments are kept. In this situation it is a straight forward operation of going through the core and picking all the items on the preference list. In many hospitals the packs and routine supplies might be in Central Supply, the generic instrument sets in SPD and the specialty trays and supplies might be in the OR. In this scenario, the cart may end up going through 3 different areas and be filled by 3 or more people over one or more days.

Once filled, the carts will need a staging area so that they can be easily transported to the procedure rooms where the cases will occur. Since most OR’s have less storage space than desired, this can become a major challenge while ensuring that you are not breaking any fire codes. Depending on location, you may need to have a designated person transport the case carts to rooms through the day. We suggest having the cart for the next case staged just outside of the OR so that there is no down time. Subsequent case carts can be brought to the room as the prior cart is brought in for the next procedure.

After the case, if the cart is used to transport dirty instruments, it should be sent to SPD and cleaned whether through an automated cart washer, or manually wiped down and cleaned with disinfectant. It should then be stored for use on another case.

If the cart is used to transport clean supplies back to the supply location, it should be emptied, wiped with a disinfectant wipe and stored for subsequent use.

Frequently we see facilities that ask their nurses and technicians to fill the case carts in between cases, or at the end of their day when the room finishes. This system can be fraught with problems. For example, on busy days there may be no one available to pick cases which can lead to overtime, or delays in the timely start of cases. This can be very costly to an organization and also leads to inconsistency in the way the cases are picked.

We recommend a dedicated person, or persons, whose role includes picking the entire case cart for each case. This person does not have to have patient care experience and can be at a lower salary level than an RN or Tech. They should be detail oriented and have good critical thinking skills. As long as the preference lists are well maintained, you can get a consistently good product from the case cart personnel. We generally call them “Core Techs” or “Case Cart Techs”.

We have been at facilities that start picking their cases up to 2 days in advance. Generally they do this to ensure that they do not run out of supply inventory or have time to get more in before the case. From our perspective, this tells us there is poor planning and possibly an inventory management issue at the facility. Additionally, this means that each case cart will be touched a minimum of 2 times (or more) because they likely cannot add instruments 2 days in advance.

We believe that the best and most efficient way to provide case carts is to build them in a “just in time” method. This means that the carts for the first and second cases of the day are built the night before. Early the next morning, typically 4 or 5 a.m. the Core Tech(s) come in, places the first carts in the room, puts the second outside of the room and then starts building the carts for the “to follow” cases for the rest of the day. The number of core techs and the time they come in will be dependent on the number of rooms and the number of cases for the day.

The most efficient way to pick a case cart is just shortly before the surgery for a number of reasons. Below are just a few:

  • Case is less likely to cancel
  • The surgical instrumentation has had sufficient time to be reprocessed and sterilized
    One person can pick the entire case in sequence and be totally accountable for its contents
  • Less potential for someone to take an item off of the cart

If there are problems with inventory, this is a separate issue that needs to be addressed. We recommend a daily huddle to review the surgery schedule several days in advance and determine if there are an unusual number of cases that require the same resources. If that occurs, you should have sufficient time to order in additional inventory to meet the increased demand.

Surgical Preference Lists

One area where we often identify variability in practice is in the process of preparing supplies for upcoming surgical cases. Not only does the process vary, but also the timing and the type of personnel performing the task. The more standardized the process, the more consistent good results are achieved. The next two months of newsletters will highlight some common errors and best practices.

Preference Lists Updates
It does not matter whether you have an automated system or a manual system of listing preferences for a procedure or physician, the key is to have a well-defined process for keeping the lists current. It is important to have a system to make these changes within 48 hours. We recommend that changes be reviewed by a specialty team leader or charge nurse on a daily basis and then given to a clerical staff person for entry into the system. All too frequently we see these changes stack up for several weeks until a nurse has time to sit down at a computer and enter them. This leads to dissatisfied physicians and staff.

If your process has been broken for a while, we recommend that you do some analysis of your cases performed before starting a major preference list update process. By identifying the top 20% of your surgeons by volume and the top 20% of cases by volume you can easily address 80% of your case load. Next, address all of the other procedures. Once the process is completed, the updated preference cards should be given to the surgeon for review and approval.

Preference List Information
When the OR information system is developed the supply file is frequently downloaded from the materials management system. We have seen many disasters with this process unless certain precautions are taken first. The first problem is that the nomenclature of materials management may be quite different from a nurse. For example, sponge-4×4 radiopaque may be known as a “raytec” to an OR nurse. The key is to have a defined methodology for how products are named and that needs to be clearly communicated to all stakeholders. The second problem is that there may be a limited number of characters available for the description. This can create havoc if there are long descriptions with size information, for example-screw, titanium, cancellous, canulated, ½ thread, 10mm. Once this is abbreviated it is difficult to figure out what it is. We have seen preference items with incomplete size information and this creates huge problems for billing and inventory management. The third problem is the absence of a location code for all of the products on the list. Location codes can be helpful in two ways:

  1. If an item is missing or gets dropped on the floor, the circulating nurse will know right where to go to get additional product.
  2. Most of these information systems can also print out the preference list as a “pick ticket”. The pick ticket will print out the items in order of location code. This speeds up the process of picking all of the items for the case.

Keeping the locations, as well as the correct items on the preference list is something that needs constant attention and maintenance. Depending on the size of your facility, it may require a full time equivalent.

Validating the List
The final step in the process before case carts are picked is to have someone review the lists that are assigned to the cases on the next day’s schedule prior to starting the picking process. This is especially important for non-routine or multiple procedures. For example, if you are doing a hysteroscopy and a laparoscopy, there may be items duplicated between these 2 procedures. It may take a nurse to review this and either create a new list or modify the two lists that may be picked for this particular patient. Once reviewed, the lists can be given to those who will be picking the cases.
Next month we will write about the case picking process.



Sterile Processing Productivity Standards

The productivity standard for Sterile Processing Departments (SPD) varies across the country. Many of the standards utilized by hospitals have very little correlation with the workload within the department. The reasons for this are multifactorial and this article will review some of the reasons and solutions.

Variable Functions
While the main function of SPD is to clean and sterilize surgical instrumentation, they may be involved with several other related duties which can impact workload to varying degrees. These duties may include items such as restocking emergency carts, building case carts for the operating room, cleaning patient care equipment used on the nursing units and in some cases, supply distribution to the hospital departments.

Many years ago sterile processing was just one of the many functions of “Central Supply”. In those days there were fewer disposable items. Most hospital supplies were either laundered or cleaned, reprocessed and distributed. Additionally, surgical instrumentation was less complex and fewer trays were needed to perform procedures. At this point in history, with this model, average daily census or patient days made sense as a unit of service. In some institutions calendar days was used and “CS” was basically considered a “fixed department”.

Times Have Changed!
In today’s environment there are many more disposable products. Many hospitals have separated the materials distribution activities from sterile processing and in many instances, hospital distributors are taking over the resupplying of the nursing unit with new distribution techniques. By utilizing lowest unit of measure “LUMS” they are delivering supplies directly to the nursing units. Additionally, patient equipment is now being cleaned on the units, eliminating the work associated with transporting it to and from the processing area. Finally, the many new surgical techniques, (i.e.) minimally invasive, robotics, total joints, spines, etc. have led to a major increase in the number and complexity of trays per case. One can argue that the patient days or calendar days is still a good measure for materials distribution, but not for sterile processing.

What should the Standard Be?
The standard should be something that can easily be captured and even better if it can be automatically downloaded into the financial software. To meet this standard, many hospitals have moved to surgical case volume as the new unit of service for SPD. This measure is far superior to the old standards, especially if you have a consistent case mix. However, if your case mix is variable, there can be frequent variances. The amount of work associated with a total joint or spine case with loaner instrumentation from an outside vendor can be 20 times greater than a simple D&C or tonsil case. For example, outside trays must be washed and decontaminated twice (before and after each case) and there may be from 5 to 10 trays per case! Even a few additional cases per month can impact workload.

If your facility is lucky enough to have instrument management or instrument tracking software, the ideal unit of service is trays processed. There are those that advocate taking this even further and stratifying the complexity of the trays. While this may be the ultimate in accuracy, it can be a challenge to implement.

The Rule of 20 (Alpha’s Rule)
We recommend counting trays as a unit of service with a standard of 20 minutes per tray. This includes the work of manually cleaning, loading the washer, assembling and wrapping, sterilizing, documenting, and putting a tray away. Some trays will take longer and some will take less time, but this is a typical average. What also works well with this standard is that you can also use it for other potential tasks such as completing a case cart, restocking an emergency cart, etc. For individually packaged instruments, 10 peel packs is equivalent to 1 tray. In this way, you have one 20 minute per UOS for all duties within the department.

Even without an automated tracking system for instruments the trays are documented on each sterilizer load sheet. These can easily be counted and submitted daily. If you find that your standard varies considerably, we recommend assessment of your work flow and processes and possibly time studies.

To Flip or Not to Flip, that is the Question

For those of you unfamiliar with the term, flipping rooms means providing a surgeon with 2 rooms so that they can start the next case without down time for room turnover. Typically this means 2 teams of nurses and 2 anesthesia providers. The surgeons really love it, but is it economically feasible? I am frequently asked whether or not it makes sense to flip rooms for a surgeon. The answer to this question is a definite “it depends”! Below are a few tips to help you determine whether or not you should consider flipping rooms for a surgeon and what criteria it should be based upon.

  1. Rule 1-require a minimum volume of cases scheduled in a day in order to get a flip room. One of the most important variables is how many cases can be done in a day, and how consistent the surgeon is in bringing enough volume to fill a day.
  2. Rule 2-The amount of time for the procedure must be consistent and predictable. How consistent the surgeon is with the time it takes to do the procedure(s) must be well understood.
  3. Rule 3 – The time it takes to do the procedure from incision to closure should be close to the amount of time it takes to get the patient out of the room, get the room turned around, the next patient in the room, anesthetized and positioned. For example, it can take over an hour to close, turnaround, prep and position a total joint patient in a room and the procedure itself can take an hour to hour and half with an efficient surgeon. A cataract turn-around can take 15 to 20 minutes, the same time it takes to do the procedure. You do not want a room and a team sitting around waiting to get started!
  4. Rule 4-You need to have enough instruments and equipment to be able to furnish both rooms through the day. If you have to move equipment back and forth between rooms, or compromise sterility through immediate use sterilization, it is better to stay in the same room.
  5. Rule 5 – There must be a qualified assistant that can close the incision in one room and assist with getting the patient into PACU. While the assistant is finishing up, the primary surgeon can be checking the next patient and helping to get them position properly, etc.
  6. Rule 6-The criteria for flipping rules must be written, communicated and consistently enforced.

The bottom line is that room flipping can provide a level of efficiency that can be quite impressive and assist both the surgeon and the hospital make the best use of available resources when managed properly. If not done properly, room and resource utilization will be compromised.

The Fear of Change

Many years ago when I was Director of a very busy 15 room OR in an urban area I thought it impossible that our operating room could survive without a night shift.
After all, the night shift prepared the rooms and spread around the supplies, instruments and equipment for the first cases of the day. We practiced in that manner for many years and it was the way we had always done it.

After managing the OR this way for 5 years, we were acquired by a new company. This new company had more aggressive productivity standards that frightened me. “How can we safely provide patient care with this new standard?” I thought to myself. Performing the same way for so long made it difficult to imagine doing something in a different way. For a while I was paralyzed with fear at having to make change and potentially impact patient care. The pressure was building and I did not know whether to just resign or to take on the challenge.

Thankfully, I decided to stay and work through the challenge. By assembling the leadership team in the OR, along with consultants from the parent organization, we looked at work steps that were being done that could either be eliminated or reassigned to others. We also analyzed case data to determine peak activity and lulls in the schedule. The result was the elimination of the night shift and transferring their responsibilities to others on both the day and evening shift. We also modified the staff schedule, surgery schedule and scheduling hours to more closely model the actual schedule history. This allowed us to meet the new productivity targets without affecting the care provided to our patients and maintaining physician satisfaction.

This experience taught me a great lesson that I carry with me every day. We have a tendency to become complacent when something has been done the same way for a long time. Even though the environment in healthcare is changing rapidly, it can be difficult to realize how we must modify our practice to meet the challenge. The goal of our team at Alpha Consulting Group, Inc. is to help perioperative leaders meet the challenge.

Operational Indicators of Performance For The Operating Room

We all know that “Turnover Time” is the most discussed performance indicator in the Perioperative arena. This is the time from one patient leaving the room until the next patient enters. In our experience in acute care hospitals, the average turnover time for all cases runs about 23 minutes. Factors affecting this could be case mix, staffing, department set up and a variety of other factors. However, this is only one of a number of indicators that should be examined and tracked on a monthly basis. Below are a few others that your Perioperative Leadership should be reporting:

  1. Physician Turnover Time, aka, Turnaround Time: This is the time from closure on one case to incision on the next case. This can be impacted by a number of factors including the turnover time, anesthesia department readiness, case cart preparation, patient positioning, and surgeon availability in the department. The overall average for this time should be in the range of 45-48 minutes, but can vary significantly based on the complexity of the procedure. This is the time most concerning to the surgeon and why there is often variation between what nursing reports and what the surgeon claims to be turnover time.
  2. First Case on Time Starts: This indicator can identify a number of process deficiencies that can affect department performance through the day. For example, there can be problems with patient preparation prior to going to the OR, there can be issues with the accuracy of preference lists and case cart development, and there can also be issues with instrument reprocessing. In our practice, we see the main reason being the timeliness of physician arrival as the key reason, but this can be masking all of the other items previously stated.
  3. Room Utilization: This is based on the hours that the rooms are used divided by the number of hours the rooms are staffed. We prefer to determine room utilization without including turnover time because a long turnover can make it look like the rooms are being utilized appropriately. The goal for most facilities should be to have a utilization rate close to 75% without turnover. The maximum utilization is typically 85%.
  4. Block Utilization: Blocks are meant for high volume surgeons who can fill a room. It should be a “reward” for consistent utilization. Blocks should be utilized at the 85% rate. If physician blocks are consistently underutilized, they must be addressed.
  5. Cases by Day of the Week: By tracking daily patterns of room usage adjustments can be made to the number of rooms and staff available by day of the week and improve efficiency.
  6. Cases by Hour of the Day: This will help determine the appropriate number of rooms to be available by shift to optimize staffing and utilization. This can also help determine the right time of day to shift to on-call status.
  7. Department Productivity: In the OR it is typically tracked by hours worked per hour, or minute, of surgery time. We see wide variation in this number across the country, but typically recommend between .12 and .13 hours per minute of time to allow for adequate staffing and time for staff development.

If all of these indicators are in alignment, there is a pretty good chance that you have a well- functioning operating room.

ERAS (Enhanced Recovery After Surgery)

Bundled payments and the ever-changing landscape of reimbursement have led to an enhancement of a movement that was started back in the 80’s when DRG’s were new. At that time we spent weeks developing care maps, or pathways of care in an effort to reduce the length of stay so that hospitals could remain profitable. Typically this was done by nurses and therapists sitting in a room developing the plan of care and then getting the physicians to agree to it in committee.

Recently I have read a number of articles talking about ERAS. This seems to be a great enhancement to this early work in the development of best practices and evidence based practice. Not only does ERAS enhance the pre-hospital education and evaluation of the patient, it also leads to a number of changes in physician practice that further reduce length of stay while increasing patient satisfaction.

For example, a recent article in OR Manager talks about the process that John Hopkins went through to improve the care of their colorectal patients. The development of the program was truly multidisciplinary with representatives from surgery, anesthesia, and nursing involved and working together. They focused on reduction of SSI’s and achieved a 30% reduction. They also changed their technique for anesthesia leading to a reduction in post-operative nausea, reduced need for narcotics, and an enhanced focus on post-operative pain control. The OR nursing staff had a renewed focus on sterile technique and there was much more open communication when breaks in technique were observed. The efforts led to a mean reduction of length of stay from .7 to 2.7 days. In the first year of the program some of the savings were offset by startup costs, but they still achieved an average savings of $790 per case. By the second year the savings increased to $1500 per case!

To some degree, there are already many hospitals that are doing this in some form with their total joint and bariatric programs. This is a great model for high volume and high cost elective procedures. We expect to see a lot more of this in the near future.

Pacemakers in the Cardiac Catheterization Lab

For the last several years the trend has been for Pacemakers and ICD’s to be implanted in the Cardiac Catheterization Lab. There are many good reasons for this change, primarily because the imaging equipment is usually superior to the C-Arm fluoroscope used in most operating rooms. In our consulting practice, we frequently assess how well the Catheterization Lab complies with Perioperative Standards. After all, they are performing surgery in these rooms, and they must meet the same standards as the operating room.

There are a number of areas to be mindful of when surgery is performed in your Catheterization Lab. The areas where we frequently identify deficiencies are mainly due to the historical differences in practice and procedures in the two areas. Below are a few things to consider and assess in your catheterization labs:

  1. Do you have well defined traffic patterns and areas that are semi-restricted and restricted?
  2. How are staff and physicians dressed when inside the procedure room? Is hair covered and masks on when sterile supplies are opened?
  3. Is the room terminally cleaned on a daily basis?
  4. When staff perform a surgery where a pocket is formed, do they count instruments as well as needles, sponges, and miscellaneous items at the beginning, start of wound closure and skin?
  5. Is their count sequence from the field, to the mayo stand, to the back table, to off of the field?
  6. Are they performing a time out?
  7. Is a debriefing occurring at the end of the case?
  8. Are they assessing the fire risk, and do they use a pencil holder for the electrocautery?
  9. Do you have an appropriate number of air exchanges, and are you monitoring your temperature and humidity on a daily basis?
  10. Have you had someone from your operating room audit the performance of the Catheterization Lab staff?

If you have answered “no” to any of these questions, you may want to take a closer look to ensure that you are in compliance with standards and can always be survey ready.

Are your Surgical Instruments Really Clean?

Typically, when we are performing a Perioperative assessment, we also review the practices in the Sterile Processing Department. I have mentioned in previous newsletters about the importance of this area and it has certainly had its share of attention by the accrediting agencies, as well as the press in recent times.

One of the key issues in sterile instrument processing is the assurance that all bioburden has been removed from the instruments. Without this crucial step, you cannot guarantee that the instruments are sterile, even after they have gone through a sterilizer. There is one way you can tell how efficient your department is and how good a job they are doing with their instrument cleaning. Take a look at the baskets of instruments after they have gone through the washer decontaminator.

e6e2e882-8824-415c-af21-f6161c4a21b5If they are lying flat, like the instruments on the right, you have a potential problem. First, when lying flat like this, it is very difficult for the water and detergent being spayed by the washer to get into the box-lock (hinge) of the instruments. This can lead to a buildup of blood and tissue. It also prevents the lubrication from the processing machine from entering. This can lead to “sticky” obstructed box locks. Secondly, just sorting through these instruments to put them back in order and ensure the set is complete takes quite a bit of time when they are so disorganized.

A better approach is to use an expandable instrument stringer that spreads the instruments apart while holding them upright in the pan. This allows both the cleaning chemicals and the lubricant to reach the innermost recesses of the box lock to ensure removal of bioburden and allow for lubrication. If you walk into your Sterile Processing Department and see a pan like the second picture coming out of your washer decontaminator, you can feel more comfortable about the cleaning process at your facility.

Another advantage to this process is to just look at how neat and organized the instruments are when they get to the assembly area. Which pan do you think will be easier to reassemble? Do you think this might also save time?


8005609a-ca32-4c36-a80b-8ea28088576bThe final step in this process change is to develop a “universal set up” for your stringed instruments. Essentially you will put the instruments on the stringer in the same sequence no matter what is in the tray. The number of instruments may vary, but they will always be in the same order. This leads to a better, more efficient department.

If you have concerns about your sterile processing department, give us a call, we can help!

Positive New Year Resolutions for ED Nurse Leaders

Since we recently started a new calendar year, this is a as good a time as any to reflect on some positive leadership resolutions that will demonstrate to staff nurses that you are the type of leader they want to associate with during this next year.

Focus on becoming comfortable and confident in your leadership “skin”.
Everyone who directly or indirectly reports to you knows that you are “the boss” and that you have great power over them. Effective leaders use this power judiciously when responding to staff questions and concerns so that the relationship remains one of mutual trust and respect.

Make time to eat at least one meal per day in the dining service where employees eat.
Sit with employees you don’t know very well or don’t know at all. Ask them to share their thoughts and impressions of the ED with you. If you make this a consistent practice, you will learn a lot about how co-workers and colleagues perceive the ED. The feedback you receive during these conversations will help make you a better, stronger and more influential leader.

Consciously evaluate whether email/texting is an effective leadership tool for you or if it has become an addiction.
I remember seeing a picture somewhere of a man sitting at a table in a nice restaurant with a meal in front of him that is untouched because he is completely focused on the emails and text messages available through his smart phone. The waiter approaches and asks if he can recommend a wine and a filter setting to the diner. The staff that reports to you might very well feel the same way about you.

Choose to be kind to yourself so that you have an available reservoir of kindness to share with others that you meet during the day.
No explanation should be needed for this one.

Hot Topics