(Third in a series of articles defining the current state the hospital O.R. supply chain. This article will illustrate the problems with the information aspect of the O.R. supply chain)
On January 9th, 2007, Steve Jobs stood before the MacWorld gathering in San Francisco and announced a new product. As the audience cheered, he introduced the device as a fusion of a music , phone, and an internet connectivity. Up until that time, if you wanted all three, you had three devices, or nothing at all. The iPhone, as it was called, was a revolutionary technology: it changed how we live and work by access to communication and information.
Its used today in ways that even Jobs couldn’t have imagined, all at the touch of our fingers. With the advent and improvements in voice recognition technology fingers aren’t even necessary: we can talk to our phones (or computers) to get instant information. We can ask our computer to locate a local restaurant. We can search for the most obscure part number on Google or Amazon and order it in seconds. And we can watch a Youtube video on how to put together or operate almost anything we can think of.
The point is that the internet and digital information technology is really good at identifying and locating things, and delivering information - on literally anything, instantly.
I tell that little story, to tell this little story…….
Bayview Hospital, Anytown USA, Room 6 (trauma room) in the O.R:
Its almost 4 pm, which is late for the O.R. regular day, and before the surgery starts, the circulating nurse and the surgical technician are setting up the room for the “add-on” case, a bad tibial fracture. The surgical technician (ST) is new, and the circulating nurse is a “traveler”, and relatively new. The case involves an trauma implant set neither one of them has ever seen. They have no familiarity with most of the instruments in the set, or how the implants relate to the surgery. Yet, the ST will be responsible for managing the tray while the surgeon is focused on fixing the patient. Its going to be a stressful case because of this, and everyone knows it. The ST is especially nervous, as the surgeon for the case is not known for his patience.
The attending surgeon and his second year resident are now in the room as the patient is put under anesthesia. Since this is a tough case, and the implant tray they are using is a new set, the surgeon would have liked the second year resident to review the technique guide on how the use the set. He’s had a frantic day, however, and forgot to mention it to the resident. The assisting second set of hands will learn on the fly during the procedure. As a matter of fact, the attending is a little vague himself on how to use the set as he has only used it once before, when the device rep was present. No rep was available today, so he’s on his own now. More stress.
The surgeon is having trouble reducing the fracture. He needs a specialty instrument from another implant set, and asks the circulating nurse to have “the other tray, the large frag tray” sent up from SPD (sterile processing, where the sets are kept.) The circulating nurse to gets on the wall phone and calls down to get it sent up to the room. The person on the other end of the phone in SPD looks up “large frag tray” and sends it up to the room. The problem is, its the Stryker large frag and not the Synthes large frag set. The case is delayed another 10 minutes while the right set is sent up. 15 minutes total of OR time is wasted.
While waiting for the tray, the surgeon realizes he is not sure about the maximum screw insertion angle for the locking screws, and has no way of looking up the information. He asks the circulating nurse to get his cell phone and has her disconnect his light cable. Covered with blood and with his arms crossed, he has the nurse dial the device rep’s number from his cell phone which he has left on the nurse’s stating in the room, and has her hold the phone to his ear when the rep answers. The rep gives him the information.
This represents the state of the art for how most O.R.s enable surgeon communication to outside the room during surgery.
The operating room is quiet but for the tinny blare of the computer speakers on the nurse’s station, tuned to a random Pandora station the circulating nurse has selected. Its Barry Manilow, but at least it beats the monotonous beep of the cardiac monitor. The surgeon is already aggravated because of the crappy music and now furthermore because the ST doesn’t know the instruments as he asks for them during the case. Now he needs bone cement to augment the tibial plateau. The circulating nurse has no idea what is currently stocked in the biologic supply cabinet 10 doors down in the “bone” room (where the cement is kept under lock and key), as the surgeon is asking for something she has never heard of before. She gets on the phone, but no one answers, so she leaves the O.R. and makes her way down to cabinet. When she is there, she notices that there are 5 different sizes of product. She grabs the largest size, just to be safe.
The surgeon is ready for the bone cement, but the nurse not only grabbed the wrong brand of cement (from which he is used to using) but 5 times more than he needs. The package has been opened, however, so they are going to use it. The problem now is that the ST has no idea how to prepare the cement, which if not done properly, could lead to a less than optimal surgical result. Under pressure, she asks the circulating nurse to read off the instructions for use. While the surgeon impatiently waits, she mixes the ingredients. 3 minutes of mixing is required, but the surgeon (used to the other product which needs only 1 minute of mixing) asks for the product “right now!!”. She hands it to him, and its implanted. 80 percent of it remains unused, and is later thrown out.
The room calls for turnover staff. The case is finished. The results of a poor information supply chain? The ST is going to have a nervous breakdown the next time she gets assigned to a tibial fracture case, especially with this surgeon. The resident was not as thoroughly prepared for the case as he could have been. The circulating nurse inadvertently wasted $ 2,000 worth of product. About 15 minutes of OR time (at about 6000 dollars an hour) was wasted waiting for incorrect equipment. And most seriously, the bone cement was not properly prepared and may subsequently crack and fail. It probably won’t, but it was not an optimal use of the product.
Anyone who has spent a good amount of time in the OR will admit that while this case is extreme, they are more than familiar with all the situations described here.
A pressing question exists: With the quality of patient care and case cost clearly affected, why does this happen?
Because of the dysfunction of the O.R. information supply chain. In my next article I will explain how Summate’s Valet software, and our Einstein datacart, will provide an important resource to help mitigate this problem, and dramatically improve patient care. And it all ties to the intersection of digital content, the fact that the internet is very good at finding and delivering information, and emerging voice recognition technology.
(for more information and articles, visit our blog at www.summate.net)
Contact: Phil Sayles