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Hand Surgeons Must Help

Hand Surgeons Must Help

By James E. Clune, MD

When we think of conservation in the operating room, time is our commodity. We try to limit turnover between cases, we make sure consents and equipment lists are ready at the time of the booking. During the procedure we limit the amount of excess motion in our hands and only use fluoro at the critical moments. The goal is to perform an exacting and successful procedure in a safe and timely fashion. I rarely have considered the physical waste we produce in the OR.

I normally have tunnel vision during a busy OR day while I focus purely on the patient and their outcome. I ignore the tangible waste from every case. The beard cover, the hat and shoe covers that I throw away every time I leave the OR to talk to a family. The heaping amount of drapes I use for a trigger finger all seem like they are just a requirement that I need to adhere to so as to keep my OR privileges. Every day it seems there is more and more equipment and supplies on the table in the OR next to me as the hand kits are “standardized” to accommodate all surgeons preferences in one tray.  A trend that was noted by our colleagues a few years ago.1

The intention of the hospitals to standardize how we dress and how we drape is noble in that the goal is to reduce surgical site infections. About 31% of hospital acquired infections are surgical site infections. Surgical site infections (SSIs) cost USD 3.3 Billion per year. The mortality rate of SSIs are about 3%. Over 1 million inpatient days are attributable to SSIs per year.3 However, increasing spending on drapes by a billion dollars does not seem to be an evidence-based approach to preventing infection. Seventy percent of the hospital waste in the Unites States comes from the OR. We can definitely do better.

The disposable drape industry is predicted to be worth USD 3.14 Billion by 2023 up from 2.3 Billion in 2017.2 I’m not saying we can’t use disposable drapes. I’m saying we can’t waste them. I’m a very junior faculty member at our university and I don’t want to rock the boat or be known as a disruptive surgeon by challenging the status quo. However, it seems that if our generation of surgeons does not get involved with the policies that our hospitals are making then we will be looking back in 20 years wondering how we got “here.” With each new drape and prepping policy there is more money wasted, more time wasted, and more refuse for the environment.

Outpatient hand procedures have infection rates of much less than 1%.4 Perhaps our approach to decreasing surgical site infections should be driven by our understanding of our unique risk factors for hand infections rather than a blanket approach prescribed by the hospital. This can only happen if surgeons become involved in the decision making at the hospital level. To reduce waste in hand surgery we need to help hospitals determine what is actually important and what factors actually influence infection rates. Each hospital has an infection control committee and it is imperative that hand surgeons be a part of the decision-making process and join these committees.

1. Albert, M.G.,  Rothkopf, D.M.,  Plast Surg (Oakv). 2015 Winter; 23(4): 235–238.

2. Awad, S.S. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surgical Infection (Larchmt), 13(4): (2012): 234-7.

3. Kwakye G., Brat G.A., Makary M.A. Green surgical practices for health care. Arch Surg. 2011;146:131–6.

4. Menendez, M.E., et al. Surgical site infection in hand surgery. Int Orthop. 2015. Nov;39(11):2191-8. doi: 10.1007/s00264-015-2849-9. Epub. Int Orthop. 2015.

Comments (3)
Veronica Diaz
July 11, 2019 9:24 pm

Dr. Clune,

I am so pleased to see this extremely important issue be raised in this forum. It’s important to point out that after the transportation and agricultural industries and the heating and cooling of buildings, the health care sector is next in line with respect to carbon emissions (see Cooler Smarter by the Union for Concerned Scientists).

I was fortunate to have Mark Baratz as a mentor, so early on in my career I was tuned into the degree of excess and unnecessary waste generated in surgery in the name of sterility. In the three years since transitioning to trays and extremity packs with reduced single use plastic disposables and drapes for my soft tissue hand cases and shoulder scopes, I have not seen an adverse effect on my outcomes or rate of surgical site infection. It has been very gratifying to engage the entire surgical team and surgical center personnel towards this goal.

This issue is one for which it is worth “rocking the boat”. The entire planet is counting on people like you to do so.


John Bull Durham
July 12, 2019 2:52 am

Could not agree more. Don Lalonde has shown us how it is done in Canada. When I left private practice one year ago 85 percent of my cases were done under local. For 4 years I struggled with the hospital and surgery center rules about limited field sterility. The beast was too much for me and backed by state and federal regulations to boot. Now as the hand surgeon for the Navajo tribe I can’t even get the hospital to allow local only cases. I find it sad that our society is in this depth of denial and lack of truth in terms of the causes for infection. Now we have improved our SSI ‘s by throwing away tourniquets after each case! My only possible response to the later is to not use them. WALANT allows for that


Robert L. Bass MD MBA
July 12, 2019 6:46 pm

All of these comments are very insightful. Who knew that many years ago when John Bull Durham was a hand fellow and I a second year resident we would be agreeing on a topic of interest some 3o+ years later. These are all issues of cost of care and how hospitals and surgeons are not behaving as responsibly as they should. Procedure after procedure for CMC arthritis has been devised, now with many of the younger surgeons using suspension implants that cost 1500-2000$ before markup. However, there have been many articles about single suture suspension with comparable excellent results. Hospitals eventually will mandate more responsible cost of care plans. It is a shame that the hospitals for Dr. Durham couldn’t see the wisdom of his attempt to do more cases under local. Baby boomers are retiring and increasing in numbers. The Medicare trust fund will be nonexistent as early as 2026. Yet when surgeons try to save the system money, we are hit with bureaucratic blockades.


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