Authors (including presenting author) :
Ngan HT(1), Cheung WY(2), Yip WY(1), Fung CK(1), Ngai YY(1), Cheng HK(1), Lee YL(2)
Affiliation :
(1) The Department of Anaesthesia & Operating Theatre Service, Tseung Kwan O Hospital (2) The Department of Orthopaedics And Traumatology
Introduction :
Due to the ageing population in Hong Kong, the demand of joint replacement surgery is huge. With the opening of the Kowloon East Cluster Orthopaedic Joint Centre in Tseung Kwan O Hospital, the total number of patients undergoing total joint replacement surgery will increase from 130 to 400 yearly In order to tackle the foreseeable demand, a working group which consists of orthopaedic surgeon, OT nurse and Integrated Disinfection and Sterilization Service (IDSS) nurse is formed to streamline the service in operation theatre. A value-stream mapping has been performed to find out the value added and the non-valued added practice and hence to increase the operation efficiency. Firstly, it is found out that nurses spend a lot of time in surgical preparation especially in instrument counting. Moreover, the cause of the prolonged counting practice is mainly due to many unused instruments inside the instrument tray. Secondly, Junior nurses found difficulties in handling a large number of instruments during the operations. They need to memorise all the instruments used during operations and this will eventually make them feel stressful. Thirdly, many necessary instruments in the instrument tray will increase the chance of passing the inappropriate instrument to the surgeon and hence delaying the surgery. Moreover, unused instruments will also increase the workload of Integrated Disinfection and Sterilization Service unit and will prolong the instrument reprocessing time.
Objectives :
The aim of this Continuous Quality Improvement (CQI) study is: 1. To increase the operation efficiency by standardisation of instrument trays and evaluating with data analytic tools. The target of instruments reduction is set to be 40% and instrument trays reduction is set to be 50%. 2. To carry out a cost-effectiveness analysis based on the cost of instrument reprocessing. 3. To decrease the total operation time and hence adding more cases within one day section
Methodology :
Workflow of the operation of the joint replacement centre is redesigned according to lean methodology in order to maximise the efficiency. At the beginning of the study, in total 5 times of observational study were done. The observational study is aimed to record the use of different instruments used during total knee replacement surgery. Moreover, we also recorded the time needed for nurses to do different tasks like instrument counting, instrument back table preparation and instrument flow inside the theatre. After the observational study, we categorize the use of the instruments by “must use item”, “standby item”, “standby item in store” and “not used item”. With the categorization of the instruments, we combine and redesign all the instrument trays according to this categorization, the practice of scrub nurse and the weight of the instrument. After the redesigning of the instrument trays, we carry out another 5 times of observational study to compare the pre and post results. Apart from the efficiency of the operation theatre, we also focus on the cost and effectiveness of instrument reprocessing. With the help of “surgical instrument track and tracing system”, we used the data from the database to analyse the instrument usage, time for instrument reprocessing and the machine usage with our analytic tools.
Result & Outcome :
The CQI project is considered a great success to improve our service. In view of the instrument trays redesign: The total number of instrument items reduced is over 40% from 269 to 163, the instrument trays were reduced by over 50% from 15 to 7. For instrument reprocessing: The washer cycle for one case is reduced from 3 to 1. The autoclave cycle for one case is reduced from 2 to 1. According to our previous calculation and other studies, the operation cost for one Washer and autoclave cycle is about HKD 50 and HKD 350 representatively. The estimated cost reduction excluding human cost is about HKD 180,000 (53%) for 400 cases (reducing from HKD 340,000 to HKD 160,000). Since the staff cost is difficult to estimate, we measured the time for them to check and repackage for one case by two staff. Assuming 5 times on average. We found that the time spent on checking and repackaging was decreased from 55minutes to 30minutes (45% reduction). For the maintenance of the instrument, in general, the life span of a single instrument is set to be 5 years. The cost of each basic instrument set before reduction was about HKD $57,530. After the reduction of the instrument, the cost of the new basic instrument set is about HKD $49,732. The difference between the cost for the basic instrument is HKD $7,798 (14% reduction). This means that the cost reduction in the basic instrument is HKD $1,560 yearly. After implementation, according to the instrument tracking and tracing system, there were 80 total knee replacement cases done. There was no record of urgent request of the removed items. Moreover, some of the removed items become standby instrument inside sterilization store, which can still be requested in a short moment. In addition, our analytic tool can help us to record any instrument that is requested by surgeons in 10% of cases, thus changes can be made in our instrument pack list accordingly. Some junior nurses reported that they feel more confident in assisting a total knee replacement surgery. According to our Preoperative Nursing Information System, scrub nurse assigned to our joint replacement centre changes from at least 3 years experience to even newly recruited nurse. The surgery standardisation and instrument trays redesign give them confidence to handle these “originally” complicated cases. The lighter redesigned instrument trays are more OSH friendly reported from IDSS staff.
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