Hand surgeons can take simple steps to achieve sustainability and savings in OR, clinic

Baratz ME. Symposium 1. Presented at: American Society for Surgery of the Hand Annual Meeting; Sept. 29-Oct. 1, 2022; Boston.

Baratz ME. Symposium 1. Presented at: American Society for Surgery of the Hand Annual Meeting; Sept. 29-Oct. 1, 2022; Boston.

BOSTON — Using smaller instrument sets and fewer disposable products can lower the cost of hand surgery cases and make these more sustainable procedures, a speaker said at the American Society for Surgery of the Hand Annual Meeting.

There are also other simple steps that hand surgery teams can take to realize savings and sustainability in the OR, and the benefits of these efforts extend to patients and impact their satisfaction, according to Mark E. Baratz, MD , of University of Pittsburgh Medical Center (UPMC).

"I’ll say to you that wide-awake surgery, life cycle assessment and vigilance to conservation is like eating a good heirloom tomato. It's good for you, it's good for your patient and it's good for your community," he said during a symposium.

Among the examples Baratz gave during his presentation on ways to save energy and reduce waste was carpal tunnel (CT) surgery. He said his thinking regarding waste and cost was transformed when he noticed how large the set to perform CT release surgery was, as well as the number of extraneous items readied in the OR for the case, such as osteotomes and mallets.

"I thought, ‘How can we get rid of this stuff?’" Baratz said. With the help of others at UPMC and inspiration from Donald H. LaLonde, MD, FRCSC, who championed the wide-awake anesthesia, no tourniquet (WALANT) hand surgery technique, the CT surgery set that hand surgeons at UPMC use was whittled down in size and cost.

"It went from that big draping system down to this, [which] got rid of most of the plastic and reduced the mass of stuff that we were using in the OR. And it mattered. Our normal pack cost about $47 and is 5.5 pounds. A small pack is $17; just over 2 pounds," Baratz said.

He and his colleagues have studied and published on life cycle assessment and the impact that the change to WALANT surgeries and being more cognizant of waste, among other steps like these, has had.

He cited a study done with Cassandra L. Thiel and colleagues, in which they examined the process with respect to patient satisfaction. He said that surgery performed with local anesthesia with a small pack had 5 pounds of trash, high patient satisfaction "and it was equivalent or better to that seen in patients [who] had local with sedation. So, did we reduce the waste? We did. Over the course of the study, it was 50 pounds less trash in just under 100 patients," Baratz said.

He described the move toward surgical savings and sustainability as a win-win situation for all involved parties. In particular, patients see benefits when their physicians adopt WALANT surgery performed in the office or clinic for hand procedures.

"Our patient has fewer and lower copays and less time devoted to getting fixed. They don't need that ride, so a family member doesn't have to take off that day of work. That may be meaningful from a financial standpoint. We know that it's safe. We know that it's at least equivalent satisfaction and, as in one of the Best Papers presented today, [with] many of these procedures, I think we can anticipate better outcomes," Baratz said.

Thiel CL, et al. Hand (N Y). 2019;doi:10.1177/1558944717743595.

David C. Ring, MD, PhD

Hand surgery without large drapes, gowns and hats, and with just a few simple instruments might seem like cutting corners and taking risks, but it is a matter of perspective. We have always done minor surgery that way in the ED. Credit to Dr. Baratz and others for adding the health of the environment to stewardship of resources as strong reasons to switch to local field drapes and to skip surgical gowns and hats. Many surgery centers also skip cleaning the floors between local patients and allow patients to walk in and out of the operating suite, which is often a smaller procedure room rather than a standard OR. Readers familiar with lean principles and other aspects of process improvement will resonate with the drive to provide excellent care using less stuff. Stay curious about how things can improve.