The Leader of the Pack

Pre-packaged surgical kits make for a smoother and more profitable surgery.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

The advantages offered by pre-packaged surgical kits for cataract surgery are well known. They offer improved efficiency by saving staff from having to pull each individual tool needed for each case, their contents are pre-sterilized, less time is required for operating-room turnover and a faster set up, and less space is required for surgical inventory.

However, custom surgical packs are not foolproof and can end up costing or otherwise inconveniencing practices if not configured properly. Ophthalmology Management spoke with some cataract surgery veterans and got their advice on how to get the most advantage from these OR staples.

Potential Pitfalls

The prepackaged surgical kits are customizable, enabling surgeons to get just the bare essentials in surgical accessories, or everything from eye drapes to blades. Some experts warn, however, that the blades offered may be less than ideal. "There's no way a stainless steel knife can compete with a diamond blade," notes John Bee, Chief Executive Officer of Rhein Medical. And many surgeons, of course, prefer the ever-sharp diamond blades.

However, surgeons say that it is easy to get around this issue. Because companies are amenable to making the packs exactly what they desire, many simply order packs that do not include knives. And higher-quality stainless steel blades are available. Alcon, which launched its Custom-Pak surgical packs in 1987, offers its Intrepid line of cataract knives in their packs.

Depending on the number of surgeons at an operating facility, they may have to compromise on other surgical tools as well. "They just have to work around it," says Mr. Bee. "Instead of opening up 2.6 on the phaco incision, maybe another doctor on staff wants to open up 2.8 and so they have to compromise and get packs that are 2.8."

Y. Ralph Chu, M.D. of Edina, Minn., agrees. As a single surgeon in his own center, he says that getting exactly what he wants in his pre-packaged kits is much easier. The more surgeons at an ASC, the more likely it is that someone will have to compromise. "I think a lot of centers, for cost reasons, are trying to get a pack that works for the majority of their surgeons, if not all their surgeons," says Dr. Chu. "Because it's about efficiency, it's easier for the staff, and it saves money.

The compromise is inevitable. Alan B. Aker, M.D. of Boca Raton, Fla., says that especially when surgeons are creating an ASC, they need to be aware of this and plan accordingly. "If you've got multiple doctors in the practice, the kits can be customized for each doctor," he allows. "But with a multiple-doctor ASC, if they're really going to achieve OR efficiency and cost efficiency (savings), they've got to sit down and come to an agreement — in fact, if they're going into an ASC, that should start with the planning phase."

"If there is not consensus amongst the surgeons at a center as what is to be used, and the amount within the pack is not pared down, they can be less efficient," says John F. Doane, M.D., clinical assistant professor at Kansas University Medical Center in Kansas City, Kan.

Dr. Aker points out that the adjustments are seldom onerous, while the advantages to creating a uniform surgical pack are many. "You will reduce costs and reduce confusion in the minds of the nurses," he says. "I've seen nurses have little cards for each doctor — that's what they did before they had pre-packs. It's the reason they needed to book 2 hours for a cataract operation: it would take one hour just to get the doctor's stuff. The cards were all about who liked this suture, who liked that glove."

Agreeing to a uniform pack has made a significant contribution to his surgery center's efficiency, Dr. Aker believes.

Alternately, some surgery centers have a "base pack" and then additional, smaller packs to suit individual surgeons, rather than going for a one-size-fits-all approach, according to Dr. Chu. "They will have a ‘Doctor A addendum,’ a ‘Dr. B addendum,’" he says. "That kind of thing."

Monitor Your Needs

Pre-packaged surgical kits can also fail to live up to their cost-saving reputation if practices don't periodically re-evaluate what they are using. "Times change," warns Brenda Trahan, B.S.N., operating room supervisor at Eyesight Associates in Warner Robins, Ga.

"If you don't customize [the packs] specifically to your needs, you could be spending more. You have a kit made up and you have it on the shelf, but if you don't review it every now and then to be sure that everything in there is still what you want, you could be spending more," says Ms. Trahan. "You decide to use something else and so if you're not checking, yes, it could cost you."

Tennessee's Larry E. Patterson, M.D., chief medical editor of Ophthalmology Management, agrees. "Only put in the pack things that you are definitely going to use in every case," he says. "That is very important."

Dr. Aker notes that at his ASC, they have modified their pack 32 times over the years. "We change our packs every time we change our technique, or every time we eliminate something. It reduces our cost and, again, it makes it easier for the nurses," he says. "You don't want anything there that you don't need, but you want to make sure you have everything you do need."

Changes in packs must be planned in advance, because manufacturers typically create a 3-month supply of packs ahead of time, Dr. Patterson points out. Surgeons must then use the inventory the company has made up for them before a change is incorporated in their packs.

"You're in a little bit of a long-term commitment," he says. "You really need to be sure when you make the order that it's what you want, because you're going to be stuck with it for awhile. So if you're thinking about changing something, you need to let them know as soon as you can, so they can start making the adjustment."

Customizing is Easy

The good news is that manufacturers of pre-packaged cataract surgery packs were uniformly reported to be very cooperative in making the packs precisely what their clients wanted.

"They bend over backwards," says Dr. Patterson. He reports that manufacturers will frequently give surgeons free samples of pack components to help them find the one that is just right for them.

"Once, we changed companies and they couldn't find the exact cystotome I used to use, and we went through probably five different models to try to find exactly what I wanted," he says. "Same thing with gloves. We went from powdered gloves to powder-free gloves, and I bet we went through a dozen kinds of gloves to find one we all liked."

"I've never had a problem making changes," seconds Ms. Trahan. "I just call my rep, who is real easy to get a hold of."

Seba Leoni, director of global marketing for viscoelastics, solutions and disposables at Alcon, reports that the company aims to meet surgeons' needs by offering a wide breadth of high-quality components for their Custom-Pak.

Mr. Leoni says that Alcon works very closely with operating staffs to achieve their ideal set of tools. "Beyond the high quality and vast options of the products offered," he says, "we also have the ability to arrange the components within the pack in the exact order the OR nurse wants it."

Efficiency, Efficiency, Efficiency

Saving as much time and money in the OR as possible have been cardinal guidelines forever, and the prospect of declining reimbursements from Medicare for cataract surgery mean they will only be even more critical. The experts interviewed here agreed that prepackaged customized surgical kits were an essential ingredient to superior efficiency in high-volume practices.

"I think if you are not using the packs, you are making big mistake," says Dr. Aker. He notes that packs not only make life easier for staff, saving "wear and tear on your nurses," they also spare expensive instruments the rigors of the autoclave.

"At the end of the day, I think the surgeons who can be the most efficient are obviously going to be the ones who are going to be most successful going into the future, given the declining reimbursement situation," says Dr. Chu.

The "Green" OR

With environmentally-friendly products currently in vogue, pre-packaged kits are also a good choice for those who seek to minimize waste.

Alcon's Mr. Leoni points out that the average Custom-Pak contains 20 products. "Imagine 3,000 procedures performed yearly at a hospital or an ASC and having 3,000 more boxes and wrapping from each of these 20 items," says Mr. Leoni. "In this instance alone, you're talking about 50,000 more boxes every year that the OR needs to dispose of. This not only creates further cost and inefficiencies for the OR, but it is clearly against where we are going as a society." OM