The Real Cost of Waste in Surgery

Incision · · 8 min read

Surgery is a high-impact place to reduce waste. In this article, we explore the complex and confronting topic of waste in surgical care and the unignorable price that this comes at. We look for solutions in some of the inspiring initiatives of teams worldwide, helping us balance the books and work together towards a brighter, more sustainable future.

Unused Supplies Waste Millions

The US healthcare system annually generates over 5 million tons of waste [1]. Within a hospital, between 20 and 70% of this can be directly traced back to the operating department [2, 3]. Daily, US operating rooms (ORs) generate up to 2000 tons of waste [4]. For reference, this is the equivalent of over five Boeing 747 jets fully loaded with waste, created every single day. Given the scale of these numbers, it would be understandable to assume that this is a somehow necessary tradeoff to deliver effective modern surgical care. Unfortunately, this is far from the case.

In 2015, a Johns Hopkins team reported that major hospitals across the US collectively throw away at least $15 million a year in unused surgical supplies [5]. As the authors explain, this often stems from the routine practice of bundling surgical materials together in disposable packages in ways designed to streamline convenience and efficiency. Even if all or most items remain unused, once open, everything is discarded after the procedure.

Perfectly good, entirely sterile and, above all, much-needed surgical supplies are routinely discarded in American operating rooms.

– Professor Richard Redett, Director of Plastic and Reconstructive Surgery, Johns Hopkins Hospital

Straight into the Bin

In a recent survey, surgeons estimated that 27% of items opened on the scrub table at the start of surgery remain unused on the table at the end of surgery [6]. These supplies bypass any form of patient contact or surgical utility to go straight in the bin. Waste on this scale comes at a huge cost, both environmentally and economically.

In California, a UCSF team found an average of $653 per procedure was wasted in unused neurosurgical supplies. This represented 13% of their total surgical supply budget, costing the hospital $2.9 million a year [7].

In the Netherlands, researchers measured the costs of single-use items that were opened but not used in neurointervention [8]. They found that the mean cost of waste was €515.09 per procedure. For very high-cost procedures, such as aneurysmal coiling, this value was as high as €1061.55 per procedure.

In France, a study of general surgical, urologic, and gynecological procedures reported a median cost of €4.1 per procedure for opened but unused supplies [9]. Compared with the two studies cited above, this is likely to reflect the disproportionately high running costs associated with neurological surgery. However, €4.1 per procedure still amounted to 20.1% of the total budget allocated to surgical supplies. The researchers estimated this to create potential savings of €100,000 per year for their hospital.

Preop or postop? Unused supplies including gloves, sutures, and hemostatic agents, left over at the end of two neurosurgical procedures. Image from: Zygourakis et al, 2017.

Once a pack is opened, everything is thrown away — whether it is used or not.

But why are we doing this? Opening something only to throw it away unused is counterintuitive and counterproductive. What can we do to make more informed, sustainable decisions? Across specialties and studies, one recommendation repeatedly emerges for reducing waste in surgical care: education is the key.

How much ..?

Do you know the going price of an endostapler? Or a top-of-the-line total hip prosthesis? A suture? A drape? If not, you’re in the majority. A common finding across this kind of research is that the end-users of surgical supplies generally don't have an accurate idea of what these supplies cost.

One study found that orthopedic surgeons could accurately estimate the cost of the implants they used just 21% of the time [10]. Others produced similar findings in general surgery, otolaryngology, and urology, with clinicians' estimates ranging from 14%−25% accuracy when asked about the cost of the materials they routinely use [11].

This lack of transparency and knowledge around pricing creates large variations in the supply costs for a procedure. A study of hand surgeons across 19 institutions in Michigan found a 4-fold difference in the supply costs between 35 surgeons performing the same three procedures. Between the most expensive and least expensive ends of the spectrum, the cost of a single procedure varied by $22.47 (and 10.9 kg of carbon dioxide) [12]. Interestingly, differences in the use of low-cost supplies such as drapes, towels, and gauze contributed most to the variations in cost and carbon.

Clinicians and clinical teams often don’t understand the price of the supplies they routinely use, creating large cost variations.

Knowledge is Power

Clinicians are not inherently wasteful. Given the knowledge and resources to make better decisions, these are generally the ones we will make. When teams are educated to select less expensive supplies, research has demonstrated consistent cost savings and waste reduction patterns, e.g., $58 per laparoscopic cholecystectomy, $442 per appendectomy, etc. [13, 14].

Tools that enable teams to make informed, transparent decisions around costs and supplies are vital. One such tool is a “Surgical Scorecard,” described in a recent article (in press) in the Journal of the American College of Surgeons [15]. This is a report delivered to a surgeon summarizing the cost of their supplies, their operation times, and how these compare to their colleagues.

Another strategy is to review and adjust surgeons’ “preference cards”: the list of instruments and supplies they request for each procedure. The Urology Department at Stanford University demonstrated that adjusting surgeons’ preference cards (in favor of removing unused disposable supplies) resulted in a 92% reduction in waste and a potential cost saving of $9880 per OR [16].

Screens from the platform Assist, a mobile app to record and share perioperative workflows, protocols, supplies, and surgeon-specific preferences in order to improve team alignment and performance.

When supply cost information is transparent and easy to access, teams can make informed decisions to reduce it.

Leaders of Leaner Processes

When informed and empowered, surgical and perioperative teams are ideally positioned to lead efforts to reduce waste. Transparent pricing and clear documentation enable us — the end-users of surgical supplies — to make the type of confident, pragmatic, practice-based decisions that we are trained for.

When healthcare workers are asked, we resoundingly want to reduce our waste and mitigate our environmental impact. A multicenter study of surgeons found that 95% were willing to modify their workflow to reduce waste [17]. In a recent survey of cataract surgeons, 92% felt that operating room waste has become excessive and needs to be reduced, and 99% were concerned about global warming and strongly wanted more reusable options [18].

Surgical teams are uniquely positioned to lead sustainability initiatives, with access to key stakeholders and the ability to initiate meaningful supply changes.

Changes in healthcare are challenging. To succeed, we need technological solutions that empower us to make transparent and informed decisions about cost and resource allocation. Together, we can share our strategies and implement the changes that need to happen — to the benefit of our environment, and our patients.

Here at Incision, we’re dedicated to writing blogs that inspire conversation, bring teams closer together and educate in a dynamic way. When we learn together we grow together, so join the conversation!

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