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Lean and Green Hand Surgery: What Can You Do?

By Robert E. Van Demark, Jr., MD

It is estimated that the US healthcare system generates 4 billion tons of waste annually (6600 tons per day). Hospital operating rooms account for approximately 25-35 % of all hospital waste and are responsible for nearly 56% of total hospital costs. Orthopedic surgery is one of the largest waste producers in the hospital.

In 2014, Mark Baratz spoke on the “Economics of Hand Surgery.” He discussed the idea of a “minimal custom pack design.” His group analyzed the contents of their surgical packs and removed all unnecessary items.  Later that year, I visited Dr. Don LaLonde in New Brunswick, Canada. I saw firsthand the concept of “minor field sterility” for wide awake local anesthesia cases. When I compared the contents of Don’s back table for a carpal tunnel release (Figure 1) to my own carpal tunnel set-up (Figure 2), I thought there was room for improvement.

Figure 1: Dr. LaLonde’s set-up
Figure 2: My own set-up

As we started using wide awake hand surgery (WAHS) in our practice, it seemed like a perfect time to transition to the “minimal custom pack design” for our cases. My own personal tipping point came when I saw the amount of waste generated by just one carpal tunnel procedure (Figure  3).

Figure 3: Waste generated by just one carpal tunnel procedure!

We began a series of meetings with Administration and staff. Eventually we decreased both the cost savings by ($10.64) of the new custom packs and the amount of waste saved (5.06 lbs) for each surgical procedure. Since starting our “Lean and Green” project in 2014, our hospital system has realized savings of $25,610.48 and decreased surgical waste production by 12,179 lbs or 6.1 tons. Our “Lean and Green” surgical packs have led to a dramatic change in the waste generated for a carpal tunnel (Figure 4). The amount of supplies on the surgical back table has also decreased (Figure 5). Patient satisfaction has remained high: 99% of patients felt that their procedure was the same or better than a dental visit. 1

Figure 4: Our reduced waste following one carpal tunnel procedure
Figure 5: The amount of medical supplies on our back table also decreased

Recently Thiel and coauthors reported their experience using minimal surgical pack design and wide awake hand surgery. Using the custom surgical packs and WAHS, they reported significant cost savings and waste reduction along with greater patient satisfaction when compared to hand surgery done using sedation and local anesthesia. 2

The Lean and Green Hand Surgery Initiative has been adopted by the AAHS, ASSH, ASRM, and ASPN. The goals are to reduce costs, reduce waste, improve safety and increase patient satisfaction. It is estimated that there are approximately 2000 hand surgeons practicing in the United States. If every surgeon would do 100 cases in a year (a total of 200,000 cases/ year), dramatic savings could be realized. Using our practice savings of $10.64 per case and 5.06 pounds of saved waste, there would be a cost savings of $2.13 million dollars and a decrease of 1,012,000 lbs (506 tons) of waste.

I would challenge everyone to critically look at their own practice and see if you have an opportunity to join the “Lean and Green” Initiative.

1.       Van Demark Jr MD RE, MS VJSS, BS AF. Lean and Green Hand Surgery. Journal of Hand Surgery. 2018;43(2):179-181. doi:10.1016/j.jhsa.2017.11.007.

2.       Thiel CL, Fiorin Carvalho R, Hess L, et al. Minimal Custom Pack Design and Wide-Awake Hand Surgery: Reducing Waste and Spending in the Orthopedic Operating Room. HAND. 2017;14(2):271-276. doi:10.1177/1558944717743595.

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