Up to 50% of Arthroplasty Instruments Unused or Underused!!

A new study tracked instrumentation utilization rates for total knee arthroplasties at two high volume East Coast hospitals: Rothman Orthopaedic Institute in Philadelphia and Main Line Orthopaedics in Bryn Mawr, Pennsylvania. The study, titled “Minimizing Surgical Instrument Burden Increases Operating Room Efficiency and Reduces Perioperative Costs in Total Joint Arthroplasty,” has just been published in the June 1, 2021, edition of The Journal of Arthroplasty.

Jess Lonner, M.D., one of the study’s authors and an orthopedic knee surgeon at Rothman, explained the genesis of the study to OTW. “Our imperative, as responsible stewards of value-based care, is to deliver the best care possible while controlling costs. As an orthopaedic community we have tackled the obvious big-ticket items—implant costs, length of stay, reducing the use of inpatient rehab and skilled nursing facilities. But there are other opportunities to control costs during the perioperative episode, which are less obvious, but equally important, particularly when taken together. It was my impression that we could improve OR workflow, reduce inefficiencies in instrument processing and ultimately help to control OR costs by ‘optimizing’ surgical trays.”

“In any given hospital, the surgical instrument trays used in knee and hip arthroplasty surgery are often poorly organized and overstocked with redundant or underutilized tools. This increases the risk of processing and sterilization errors, increases processing time and expenses, increases the risk of error in tray preparation, increases the time it takes for the OR technician to set up the table, and it puts those who have to lift the heavy trays at risk of work-related injuries from muscular strain. This issue has been looked at in other surgical specialties and a little bit in the subspecialty of knee and hip arthroplasty, but we wanted to study the use of Lean methodology at one hospital to determine the potential cost savings by paring down instrument trays.”

The team randomly selected 35 elective primary total hip and knee arthroplasties performed by four fellowship-trained surgeons. An independent observer noted the type and number of instruments used as well as the timing of different steps in the sterilization process. Using the principles of Lean methodology, the “…surgeons identified redundant or underutilized instruments and agreed upon the fewest number needed for each tray. Instrument utilization rates and processing time were analyzed before and after tray modifications. Annual cost savings were calculated based on a processing factor of $0.59-$11.52 per instrument.”

Rude Awakening

“What we found was stunning,” said Dr. Lonner to OTW, “but not necessarily surprising. When we observed the percentages of instruments in a surgical set that were being used by several different surgeons, it turns out that between 40% and 50% of instruments were unused or underutilized. In our analysis, removing unused instruments and suggesting that surgeons use ‘comparable’ yet redundant tools in some situations, resulted in considerable savings in instrument tray sterilization and processing times and OR table set up times…leading to substantial direct and indirect cost savings. In one particular hospital, through the application of Lean methodology, total instrument count could be reduced by roughly 1/3 and the number of instrument sets could be reduced by up to 2/3 in some cases, leading to 40-150 minutes saved during the sterilization process and potential cost savings of nearly $300,000 per year on average for a 1,500 joint replacement case volume.”

“This paper could have substantial implications for hospitals with ORs and perioperative processes which are inefficient (probably the majority of hospitals) and which are looking for ways to control costs, improve workflow, eliminate inefficiencies in the arthroplasty space (definitely the majority of hospitals).”