Actual Per-Procedure Cost
Purchasing and processing of disposable kits were as follows: $1.16 for suture removal kit, $4.72 for laceration repair kit, and $209.79 for incision and drainage kit (Table 1). The processing cost for each kit was calculated using weight-based estimates. The total institutional waste processing cost per month was $80,451. Sharps accounted for 2.5% of the waste, with an estimated $2,011.28 per month. Average sharps waste was 11,314 pounds per month. Thus, the sharps waste processing per weight was $0.01 per ounce.
Per-use processing cost for OR Trays was $27.65 (Table 2). Average annual resident salary for FY 2017 was $62,643, which averaged to $16.31 per hour based on an 80-hour workweek. Resident labor costs were calculated to be $27.06 per procedure, with average consultation length of 1.66 hours. Thus, the average per-procedure cost of all logged cases was $105.03 (Fig. 1).
Estimated Per-Procedure Cost
The cost of purchasing a custom PRS tray that would be available on-site in the ED was calculated to be $1,421.55 through a single vendor (Fig. 1). The theoretical per-use processing cost of this tray was calculated to be $9.88 (Table 3). Resident labor costs were calculated to be $19.41 per procedure with average consultation time of 1.19 hours. Procedure lengths requiring the use of OR Trays were removed from average consultation time calculation as described in methods. Thus, the estimated average per-procedure cost of all logged cases was $26.67 (Fig. 1).
Estimated Cost Savings
The purchase and use of a single on-site PRS tray would yield per-procedure cost savings of $88.36 ($7.65 in resident salary costs and $80.71 in material costs). It is estimated that PRS residents perform 1 procedure per day in the ED on average versus the logged 16 procedures over 4.5 months. Thus, the logged procedures likely represent about 12% of actual procedures performed during the study time period. The cost of purchasing a single new PRS tray would be redeemed after about 16 uses of the tray or within about 2.3 weeks with 1 procedure per day use. The purchase of 4 PRS trays with an up-front purchasing cost of $5,686.20 and annual cost savings of $32,251.40 at 1 procedure per day would yield projected cost savings of $26,565.20 in the first year of PRS tray use.
With the rising costs of health care in the United States, the importance of implementing cost-saving measures is paramount. Plastic surgeons have pioneered office-based procedures and demonstrated their cost-effectiveness in the private practice setting.6 It would follow that optimizing PRS procedures in the acute setting in the ED would also yield cost benefits. This study supports the hypothesis that custom and reusable PRS procedure trays available in the ED for PRS use would yield time and cost efficiencies for our institution. Therefore, an initial up-front financial investment for the purchase of custom PRS trays would likely improve quality care delivery to patients.
This study is limited by small number of logged cases, which likely underrepresent actual number of procedures completed during the study time period. Based on informal resident survey after study completion, the actual number of bedside procedures completed by PRS residents is about 1 procedure per day. Thus, our study underestimates actual completed procedures by 88%. The number of procedures completed by plastic surgery residents in the ED will only increase in the coming months to years. Specifically, at our institution, nontrauma adult ED visits are estimated to increase by 6.51% per year, with 83,520 projected ED visits in the year 2021.7 To address this increase in volume, our ED is expanding from a 36- to 41-bed unit. In addition to nontrauma visits, the institution expects 2,700 level 1 trauma visits per year once the trauma center opens in January 2018.7 The expansion of emergency care services is projected to improve efficiency by decreasing average wait times from 7 to 4.5 hours. ED expansion is also projected to provide access to care for patients, 5,011 of whom in 2015 left the ED without being seen.7
In addition to increases in procedure volume, ED procedure variety and complexity will likely increase. Patients treated at our institution are already high acuity—45% of patients presenting to the ED were triaged to the 2 highest acuity categories.7 Our patients are also complex—23% of patients receiving emergency care were admitted for inpatient care.7 Trauma-related acuity and complexity will only increase the demands on emergency services. Life- or limb-threatening conditions will take priority over less acute trauma when it comes to operating room time and resource allocation. Thus, infrastructure for performing more complex procedures under monitored sedation or regional anesthesia may become necessary in the ED for a subset of trauma patients that do not fit the highest acuity (eg, “E.R. to O.R.” criteria) or lowest acuity (“E.R. to Home”) categories. Thus, with anticipated increases in volume, acuity, and complexity of patients at our institution, the availability of high-quality, on-site PRS specialty-specific procedure instruments is essential to efficiently delivering care to a subset of trauma patients in the ED.
Our study also aimed to factor in a cost associated with time spent per procedure, using time per consultation and resident salary to estimate associated costs. Notably, the procedures involving the use of remote OR trays took 3 hours longer on average than those that only required on-site disposable instruments. The reason for longer procedural times for those involving remote OR trays than on-site disposable instruments is unclear. This difference could be attributed in part to the cumbersome process of obtaining OR trays and/or increased complexity of these procedures that required the use of OR trays. It is also possible that the procedures took longer because they were more complex, thus necessitating the need for instruments for an OR tray. Other unknown factors that may contribute to length of procedure (evaluating multiple consults simultaneously, needing to wait for ER sedation, etc) may have impacted procedure length. In addition, resident salary was the best available factor to calculate time-associated costs in this study, although not completely accurate given that residents are not hourly workers.
Multiple factors may have contributed to higher procedural costs using disposable instruments. First, in several occasions, multiple different disposable kits were opened for a single procedure. The different disposable trays available in the ED contain different types and quality tools. Thus, although the disposable tools are unsuitable for more delicate repairs, tools from multiple trays may be needed. For example, the tissue forceps in the laceration repair kit have larger teeth than those in the suture removal kit, and the I&D kit contains smaller smooth forceps without teeth, the latter 2 of which may be more appropriate for delicate repairs. Neither the I&D kit nor the suture removal kit contains a needle driver, which is required for laceration repair.
Another factor contributing to higher procedural cost for procedures using disposable kits was the relative expense of the I&D kit. There were 4 I&D procedures that were completed and 6 I&D kits that were opened in this study. Two of the I&D kits were opened in a setting that did not involve and I&D (nail bed exploration/repair, finger laceration repair; and hand laceration repair); thus, the use of a scalpel alone versus an I&D kit in these cases may not have accomplished the goal of the procedure. For the 4 cases requiring an I&D, exchanging the cost of opening an I&D kit for a single disposable scalpel that costs $1.50 would result in the following change in cost difference. Average material cost per procedure would decrease to $35.68 from $82.79 and average total cost (material plus labor) per procedure would decrease to $62.75 from $115. If a disposable scalpel is used instead of opening the custom PRS tray for the 4 I&D procedures, then average per-procedure material cost would decrease to $5.82 from $7.26 (cost of processing a custom PRS tray for each procedure) and an average total cost (material plus labor) per procedure would decrease to $19.48 from $26.67. Thus, purchase and use of a custom PRS tray would still yield a per-procedure cost savings of $29.86 in materials ($35.68–$5.82) and $43.27 in total per-procedure cost ($62.75–$19.48). Although using a single scalpel in some situations may be more cost-effective than opening either a disposable I&D kit or a custom PRS tray, the overall benefit of the availability of a custom PRS tray outweighs its purchasing cost. At the rate of 1 procedure per day, the cost of the purchase of a single custom PRS tray at $1,421.55 would be redeemed at about 1 month (32 d) instead of 2.3 weeks as originally calculated.
Finally, the training level of the resident completing the procedure may impact the length of certain procedures. In revisiting the data, the following was noted: logged procedures were completed by post-graduate year (PGY)-2 (n = 4), PGY-3 (n = 5), PGY-4 (n = 3), and PGY-5 (n =4) residents. Length of procedure did not correlate with PGY level (R2 = 0.012) and in fact were most variable for the PGY-2 (range: 1–4 h) and PGY-5 levels (range: 0.3–5 h). Quality of the instruments used for repair may impact both the quality and the length of the repair. For example, use of relatively large disposable tissue forceps that require more force to adequately retract tissue may damage the soft tissue more so than using smaller reusable Bishop forceps with small teeth. Although choice of specific instruments may vary depending on training level, the availability of higher quality instruments for repair regardless of training level will improve the quality and efficiency of the repair across all training levels.
The cost analyses in this study focused on the impact of available quality procedural instruments in the ED for PRS use. Thus, the financial impact of other materials required for ED procedures (eg, medications, sutures, dressings) is not known. Additional studies and analyses are required to optimize cost and efficient use of these materials in the emergency care setting.
In addition to improving access to quality, efficient patient care, the institution of the above tools and processes will fulfill 2 goals of the ACGME. First, the ACGME has instituted a physician well-being initiative to help prevent physician burnout, including among trainees.8 Instituting more efficient processes by specifically providing plastic surgery residents with appropriate tools to complete clinic work will help in achieving resident well-being. Second, both the ACGME and educators within plastic surgery have identified quality improvement as a core competency that resident physicians should begin to develop during training. The completion of this project and future extensions of it will help residents in our program achieve this goal.2,3,9
Moving forward, the next steps of this quality improvement project include the following: (1) the actual purchase of PRS trays; (2) the development of processes to store, transport, and process PRS trays as they are used on-site in the ED; (3) and the calculation of the actual cost savings accrued through the use of PRS trays in the ED. This project and those that follow will optimize the processes and procedures that deliver cost-effective and efficient care to patients cared for by the plastic surgery service in the acute care setting.
The purchase of specialized procedure trays will yield valuable time and cost savings while providing quality patient care. Improving time efficiency will help achieve the ACGME goals of maintaining resident well-being and developing quality improvement competency.
1. Hultman CS. Procedural portfolio planning in plastic surgery, part 2. Ann Plast Surg. 2016;76:S347–S351.
2. Schwentker AR. Quality improvement for plastic surgery residents: curriculum development. Plast Reconstr Surg Glob Open 2016;4:e1107.
3. McGrath MH. The plastic surgery milestone project. J Grad Med Educ. 2014;6:222–224.
4. Mhlaba JM, Stockert EW, Coronel M, et al. Surgical instrumentation: the true cost of instrument trays and a potential strategy for optimization. J Hosp Adm. 2015;4:82–89.
5. Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219:646–655.
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
6. LaBove G, Davison SP. Cost analysis of an office-based surgical suite. Plast Reconstr Surg Glob Open 2016;4:e803.