Content about Operating theater

MISSION, Kan. — Since the 1960s, when disposable products first appeared in hospitals, the textile services industry has fought a largely losing battle against disposables for market share. As a result, many healthcare professionals have only known single-use disposable items in the operating room (OR).

However, the current focus on sustainability, combined with education, is starting to make a difference in how healthcare professionals view reusable textiles. For example, several healthcare groups have recommended that member hospitals increase their use of reusable textiles in order to minimize waste and its associated disposal costs. And the textile services industry now has life-cycle analyses and case studies that support reusable textiles as the environmentally preferable choice over single-use disposable items.

The American Reusable Textile Association (ARTA) recently conducted its second webinar for Practice Greenhealth on the benefits of reusable surgical textiles. The information from that webinar and other ARTA resources is presented here for the consideration of suppliers and laundry operators.

COST-EFFECTIVE, SAFE AND SUSTAINABLE

Those who have worked in healthcare for more than 30 years may remember the reusable gowns and drapes used before disposables were introduced. But today’s reusable healthcare linens, gowns and drapes are dramatically superior to those used in the 1960s. Consider the facts:

Reusable surgical textiles meet or exceed AAMI standards. Indeed, reusable gowns and drapes meet or exceed AAMI³ barrier protection standards required in the healthcare environment for Level 1 to Level 4 gowns. And reusable gowns and drapes often offer a more comfortable alternative to single-use disposable gowns and drapes.

LCAs prove reusables have a smaller carbon footprint. In addition, several life-cycle analyses (LCA) have confirmed that reusable surgical gowns and drapes are environmental preferable over single-use disposable products.

The 2009 life-cycle assessment study conducted by the University of Minnesota Technical Assistance Program (MnTAP) examined three areas: cost, environmental impact and infection prevention. In summary, the research conducted at the University of Minnesota Medical Center⁴ (2,000 beds and 20,000 surgical procedures a year) found that reusable medical textiles (chemo, isolation and surgical gowns) provided cost savings of $360,000 per year, reduced waste by 254,000 pounds per year, produced CO2 emissions three times less than disposables, and produced carcinogenic emissions 16 times less than disposables (i.e. arsenic, chromium, lead) while offering the same infection prevention attributes.

Earlier studies conducted in 2008 by the Textile Rental Association of Australia⁵ and in 2000 by the European Textile Services Association confirmed similar findings.⁶

Case studies build credibility among healthcare professionals. A study in the Journal of the American Medical Association reports that about 80% of surgical drapes and gowns now used in hospitals are disposable. It estimates that by using reusable linen products and recycling other items as able, hospitals can reduce surgical waste by 73% in weight and 93% in volume.⁷

A study in The American Surgeon compared costs incurred by two similar hospitals — one used disposable gowns and the other reusable gowns. Annual expenditures were $66,000 and $25,000 respectively.⁸

Winter Haven Hospital, Winter Haven, Fla., converted to a reusable surgical textile program in 2001. Within five years, the cost savings were found to total $625,000.⁹

Kaiser Permanente’s use of reusable surgical gown and basin sets reduced the organization’s regulated medical waste by 30 tons, at a savings of 3.8% in 2010, according to Andrew Knight, senior sourcing director of Kaiser Permanente in San Diego.¹⁰

HOW TO CONVERT TO OR INCREASE USE OF REUSABLE SURGICAL TEXTILES

For a supplier or an operator of an on-premise or commercial laundry or a laundry cooperative, sharing the facts can warm healthcare clients to the pitch to convert to, or increase the use of, reusable surgical textiles. But they may need hands-on help in getting a surgical textile program started.

They could be looking for assistance with product selection, budgeting, storage layout and inventory levels. Touring a laundry that processes reusable surgical textiles might be beneficial. Their ability to gather information and build support may be the key.

What are some ways to increase the use of surgical textiles in the OR?

Reusable Surgical Towels — Offering reusable surgical towels for the OR can be an easy, logical “foot in the door.” Some suppliers now tout a disposable surgical towel that can be reused. Yes, these products can survive a wash or two, but they cannot be compared to a woven, reusable surgical towel for effectiveness, sustainability and durability.

Reusable Surgical Gowns and Drapes — Today’s surgical textiles provide comfort, flexibility, breathability, safety, fluid barrier performance, strength and durability, and low rates of particle release (linting). Upfront costs for switching to or increasing use of reusable gowns and drapes can seem expensive, but case studies show a well-managed program is actually more cost-effective than using disposables.

As a bonus, when hospitals switched to reusable gowns and drapes, they saved substantial sums by retrieving lost surgical instruments that would have been thrown away.

For example, the University of Maryland Center moved to reusable textiles in the OR more than 15 years ago, and utilizes a vendor to provide clean, sterilized textiles. In 2010, the medical center avoided creating 138,748 pounds of waste as a result of using reusable textiles in the OR, which correlates to estimated cost savings of nearly $39,000 in disposal costs and an estimated $39,000 in returned instruments (which would have been thrown away if the hospital was using disposable gowns and drapes in its OR).¹¹

Custom Surgical Packs and Hybrid Packs — For clients using disposable surgical packs and throwing lots of items in the trash, custom packs (sterile or non sterile) or hybrid packs (including key disposable items with reusables) could be an alternative.

While hybrid surgical packs and increasing recycling of items is helpful, even reprocessed disposables must eventually be thrown away. According to Dr. Rafael Andrade, a general thoracic surgeon at the University of Minnesota Medical Center, Fairview, the larger goal is to resume the old practice of relying on permanently reusable equipment.

“We’re just trying to undo a lot of the damage we’ve done,” he says. To that end, Andrade and a nurse, Lynn Thelen, started an O.R. Green Team at Fairview. With input from colleagues, they reviewed 38 types of OR packs, identified which supplies were never used (such as plastic basins, catheters, syringes and dressings), and asked their medical product vendor to remove them. One kit for implanting an intravenous port in chemotherapy patients contained 44 items, but the Green Team downsized it to 27 items and switched disposable gowns and linens for reusable ones. This effort eliminated a pound of trash and $50 in supply costs per procedure. In the first year, the various kit reformulations eliminated almost 8,000 pounds of waste and saved $104,658.¹²

FOOTNOTES

3) Association for the Advancement of Medical Instrumentation. 2005, P. 957-958. Selection and use of protective apparel and surgical drapes in healthcare facilities. Arlington, Va.

4) University of Minnesota Technical Assistance Program (MnTAP), Catherine Zimmer and A.J. van den Berghe, 2009.

5) Life Cycle Assessment Comparing Laundered Surgical Gowns with Polypropylene Disposable Gowns, The Australian Textile Rental and Laundry Association, prepared by the Centre for Design at RMIT University, Andrew Carre, 2008.

6) Life Cycle Assessment of Surgical Gowns, Anders Schmidt, PhD, dk-TEKNIK Energy & Environment, April, 2000

7) Tieszen ME, Gruenberg JC, A quantitative, qualitative and critical assessment of surgical waste. JAMA 1992;267:2765-8.

8) Cost Containment in the Operating Room, TAS, Oct. 1992.

9) Winter Haven Hospital Case Study, Conversion to Reusable Surgical Textiles, Winter Haven, Fla., 2006.

10) Regulated Medical Waste Reduction and Minimization, Inova Fairfax Hospital, Case Study, Guidance Documents, Greening the OR, Practice Greenhealth, 2011.

11) Reusable Textiles in the OR, The University of Maryland Medical Center, Baltimore, MD, Case Study, Guidance Documents, Greening the OR, Practice Greenhealth, 2011.

12) Dr. Rafael Andrade, surgeon, University of Minnesota Medical Center, Fairview, speaking at CleanMed 2010, organized by Practice Greenhealth, quoted in New York Times, June 5, 2010, issue, reporter Ingfei Chen.

Check back Thursday for Part 3: Change is hard

CINCINNATI — Setting up a surgical pack room for a healthcare laundry facility takes more than a little thought and planning. A recent webinar, sponsored by the Association for Linen Management, featured Jim Sprout, the pre-pack business manager for Standard Textile Co. in Cincinnati.

Sprout detailed the key elements in developing a successful pack room program, starting with what hospitals are looking for from service providers.

“What do they want from us? Cost savings, staff preference, environmental impact and a partnership,” says Sprout. Such a partnership, he says, is a key relationship, as is the partnership with the manufacturer that makes the towels, gowns and other linens for your healthcare facility.

OTHER KEY ELEMENTS

The other major elements in putting together a pack room program include the facility, the staff, the products to be provided, and a strong quality-assurance program.

Sprout says a textile manufacturer can provide invaluable information to a healthcare laundry.

“We know how to launder this (linen), we get all the testing, we develop the fabric, we register it with the government, and only we know how we washed it 75 times,” he says. “Whomever you buy any product from, you should base your laundry formula on what the manufacturer recommends.”

Always register products, Sprout encourages, and rely on the manufacturer for product support when anything goes wrong, as well as for program support.

Many manufacturers also can provide clinician support, including access to a nurse to help provide technical information and representation with a laundry’s clients.

“We think it is important if you want to be a partner with an OR (operating room staff) that you add some sort of clinical expertise available on your side.”

As for the facility, Standard Textile has developed a pack room layout that may prove helpful. Ask a number of questions, Sprout recommends, including the type of storage needed, whether your facility will be sterilizing or distributing packs, where offices, locker rooms, bathrooms and break rooms will be, where the quality assurance testing will be accomplished, and more.

The main requirements are proper air exchanges—no air venting from an area contained soiled linens, and clean air coming in; an ability to seal the pack room, and that the surfaces be cleanable.

Sprout says large light tables, 6 feet by 8 feet, with red lines to guide folding are also essential. Other considerations to take into account are shelving and reject bins, as well as a repair station.

Standard Textile’s approach to facility design, he says, is to have a large space, at least 140 to 160 square feet per worker. This enables the facility to have plenty of storage space—key to maintaining an efficient and orderly pack room—and lots of room to move about. But he also says it’s not good to have workers searching a pack room for materials.

“We prefer to have everything already sorted, already stacked, already organized so the workers who make the packs don’t have to do the search.” It’s best to have one person designated as the material handler, who takes away finished products and who brings in raw products, Sprout says.

His company’s approach also recommends keeping inspection, folding and pack-making functions all in the same area, and it suggests more formal and focused training for pack room workers.

Product selection is a key element to a proper pack room, Sprout says. Know the product’s performance characteristics, evaluate current and potential products, and continually review the products.

QUALITY ASSURANCE

A quality assurance program is a major element to consider, Sprout says. He listed 11 parts of a sound quality assurance program.

One, ensure that all items are folded the same. Engineers as well as OR nurses have designed folds for certain pieces of linen, such as surgical gowns. Two, inspect the materials, although perfection is not the goal, he says. The inspection criteria should be specific, documented, constantly reviewed and constantly adjusted. Three, know the age of the products being used. “We test our products to be sure they are good for 75 uses. … It’s not enough to just date it. … The simple way is to mark in red. Many places now use bar codes, and several even use RFID. Ours supports all three systems.”

No. 4 is accountability, Sprout says. A facility must be able to track every item and every pack back to the person who processed it: the inspector, the assembler, the sterile lot, etc. Next on the list is environment, meaning that the space and workers must be clean and that access is limited.

The sixth principle to a sound quality assurance program is item repair. The manufacturer will list recommendations for types of patches, placement of patches and the number of times an article, such as a gown, can be patched. “We think it is important to have repairs done only within fairly tight restrictions on methodology and types of repairs.”

Barrier testing is No. 7 on Sprout’s list of elements for quality assurance. While a brand-new product meets barrier expectations set by a manufacturer, a barrier can be compromised. “We believe barrier testing should be done on a regular basis. We think it is important that you monitor barrier performance on a daily basis.”

Pre-printed labels are best, Sprout says, to cover the eighth item on the list. Packs have to be labeled, he says, and they have to be labeled accurately. Sterilization is No. 9, and is a critical part of quality assurance, he says. Inventory management—knowing when materials levels are down and being able to order them before it hits a critical point—is imperative, he says. “You simply can’t run a pack room and wait until the workers come out and say, ‘We’re out of gowns,’ because then it’s too late. And users absolutely rely and depend on having those sterile packs where they need to be.”

The last item on Sprout’s list is complaint handling. A facility requires an easy method to communicate any issues that might arise. “We think the more information you get about any dissatisfaction that users have only strengthens your ability to be successful.”

WHAT HOSPITALS ARE LOOKING FOR

Sprout also touched on what hospitals are looking for from a provider of surgical packs. Primary is cost savings, and while this is important, Sprout says hospitals are often reluctant to provide information to allow a cost analysis. When talking about the cost savings of reusable linens vs. disposables, Sprout suggests sending a team that includes a clinician to the hospital to demonstrate the benefits.

Hospitals also are looking to make their staff happy, and studies have show that clinicians, including surgeons, prefer reusable gowns to disposables. Environmental impact is a growing concern for many healthcare facilities, and Sprout talked about a European study that shows reusable gowns cause only one-third to one-half the environmental damage caused by a disposable gown. The study points mainly to energy use, water consumption and regeneration of chemical carcinogens as the main factors to consider in the debate. The laundry process alone takes less water to wash a gown than a manufacturer uses to make a disposable gown, he says.

Other environmental studies have reached the same conclusion: the impact of using disposables is far worse than using a reusable product.

The other item that hospitals are looking for is a true partnership, Sprout says. This is where access to a clinician is so important for a pack room. “Not only Standard Textile, but other companies as well have clinical nurses available to help you with surgical linen issues, people who can represent you.” Communication is another point in a partnership, he says. The best accounts have committees that meet monthly or quarterly to discuss any surgical linen issues and keep improvements going on a continual basis.

OTHER FACTORS

Sprout touched on recent updates to the industry. First off is the change to OR towels. He touted the movement toward synthetic towels as a way to eliminate lint in operating rooms. Other changes are the improvement in monitoring of sterilization through biological indicators and the improvements in fabrics.

Unique device identifiers are on their way, Sprout says. “Every device you make, you need an identifier. In the long run, we’re going to have to bar-code or add RFID to pack labels.”

Lastly, Sprout mentioned sequential wrapping, which has changed the dual-wrapping and separate-wrapping procedures. With two-ply wrappers, a facility saves time and money, and Sprout says that “if there are pack rooms that wrap every single pack two completely separate times with two completely separate methods, that’s wasteful, and that’s an opportunity to cut back that time spent almost in half.”

Hospitals’ reluctance to change without a cost comparison is major. “The biggest hurdle is getting the cooperation of a hospital to turn over enough of their costing structure for disposables so that we can convince them that the savings we are projecting are reasonable, accurate, real and achievable.”