Custom Surgical Packs: What’s on Your Instrument Tray?

Consider these recommendations for ensuring your ASC is current.

By Sean McKinney, Contributing Editor

The contents of a custom surgical pack, a staple of the ASC, should never be considered a permanent solution — at least from a planning perspective. Instruments, equipment, technology, supplies, manufacturer services and the needs of an ASC are constantly changing. Read on to learn how even minor adjustments can pay big dividends.

Alan Aker, shown performing cataract surgery with assistance from Linda Schopper, COA, CST, provides manufacturers with estimated numbers of surgical cases 6 to 12 months in advance to secure the best pricing on his custom surgical packs.

Value in Small Gains

“Custom packs benefit an ASC of any size or scope, as there’s a savings associated with personnel time involved in assembling equipment,” says Richard Tipperman, MD, of the Main Line Surgery Center, Bala Cynwyd, Pa. “When creating a standardized pack, you can also work with several vendors to determine a best-value pack. However, the real advantages of custom packs occur as the number of surgeons and number of cases increase. Having a standard pack that every surgeon can use drastically simplifies inventorying equipment while reducing overall cost per case. In an ASC that performs 2,500, 5,000 or 7,500 cases per year, even a $3 to $5 cost savings per pack translates to significant savings and efficiencies.”

Wayne F. Bizer, DO, medical director at the Foundation for Advanced Eyecare in Sunrise, Fla., says both manufacturers and cost-conscious ASCs benefit from the use of pre-prepared packs. “For example, a company will include its viscoelastic product of choice in a pack at a much lower cost than if it were purchased separately,” he says. “This reduces the cost of the total contents of the pack, but it also locks you in to using the company’s pack and thus its viscoelastic.”

Efficiency made possible by custom surgical packs can translate into less time spent in the eye, resulting in a safer and better outcome for the patient, says Alan Aker, MD, Boca Raton, Fla., owner and operator of the Aker Kasten Eye Center along with his wife, Ann Kasten Aker, MD. “The custom packs can also reduce staffing costs. Items don’t need to be handpicked the day before or morning of surgery. Flow improves and turnover times can be drastically reduced, shortening the time the entire staff spends in the OR. Reducing staff time in the OR significantly reduces ASC overhead,” he says.

What Might be Missing?

Every surgeon prefers specific items in a custom pack. It’s possible, for example, to include a disposable, toothed-capsulorhexis forceps in your custom pack. “I prefer this because it eliminates the need for an instrument exchange,” says Dr. Tipperman. “Prior to including this in my pack, I would begin with a cystotome to initiate the rhexis and then switch to a capsulorhexis forceps. The disposable forceps enables me to accomplish this portion of the procedure more efficiently.”

Dr. Aker says a patient skin prep kit is a good addition. “The circulator can easily move it to a prep table and continue to open the sterile pack for the scrub assistant,” he says.

Bret L. Fisher, MD, medical director of Eye Center of North Florida, Panama City, Fla., says his ASC recently added sterile 5% povidone-iodine (Betadine) solution for preps. “This eliminates the need to mix Betadine with saline before each procedure, saving time and resulting in fewer patient complaints of burning,” he explains.

Removing Non-essential Items

Dr. Tipperman says sutures, tying forceps and Westcott-Type scissors are no longer necessary. “Surgeons rarely need them for routine cataract surgery. In this day and age, it’s more efficient to have a pre-wrapped suture kit available in the OR. In the rare cases that require suturing, the circulator can open the suture kit and provide the sutures, tying forceps and Wescott-Type scissors to the scrub nurse,” he explains.

Dr. Aker and others use diamond knives, excluding disposable blades from the custom pack. “Establishing the simple rule that the surgeon is the only individual to open and close the diamond blades has the potential to save thousands of dollars in possible damage to this fragile instrument,” he adds.

Surgeons typically expressed their strongest differences in opinion over blades. “We should be willing to sample and use a variety of blades — again, in the spirit of responding to changes and advances in cataract surgery,” says Dr. Tipperman. When possible, he recommends guarded blades. “They can dramatically reduce inadvertent sticks or injuries in the OR, as well as exposure to bloodborne illnesses,” he notes.

Updating Your Pack

Dr. Tipperman sits with his primary scrub nurse and director of nursing every 6 to 12 months to review his instruments and equipment, based on usage. “Often, they’ll have a different perspective, which can be helpful,” he says.

Dr. Bizer conducts “a simple time study” to determine how much labor is needed to pull together the supplies and instruments required for each case. “Then you can extrapolate your finding to the center volume,” he adds. “Comparison of this cost to pack pricing becomes easy.”

Dr. Aker revisits his pack yearly. “It can be advantageous to have meticulous circulators track unused items that are being thrown away,” he notes. “Your staff is a great resource to help eliminate waste. Ask yourself basic questions. Have you moved to topical anesthesia? Then remove the eye pad from the pack. Do you use all 10 surgical spears on each patient? Do you need surgical spears at all? How many 4×4 gauze pads do you need? These packs can be customized down to the exact number of items. You would be surprised how much money is spent in a year on eye pads that are never used.”

Review lists put together by your scrubs, adding and deleting as needed, says Dr. Fisher. “Are the surgeons on the same page philosophically — using disposable versus reusable items, for example?” he asks. “We use as many disposables as possible, the biggest exception being that both of us prefer diamond blades to disposable steel blades.”

Some of the more important components of custom surgical packs are the most basic, such as patient drapes.

Working With Other Surgeons

Key considerations are needed if multiple surgeons work in an ASC. “At our ASC, we have the basic pack that includes what everyone uses,” says Dr. Bizer. “The surgeon-specific items are added to the table as required. It’s a good idea to establish a common denominator pack and then to supplement each case individually.”

If the same specialty is involved, Dr. Aker says the number of surgeons sharing an ASC shouldn’t matter. “An ideal move would be to have all of the surgeons meet with the pack rep with samples in hand,” he says. “To reap the full monetary benefits, all of the surgeons need to agree on the items to be placed in the pack. This isn’t a time to be attached to a certain glove or gown. Agreeing on gowns, gloves and the patient drape is essential.”

Dr. Tipperman also encourages compromise among surgeons. “Unfortunately, these aren’t necessarily characteristics that define surgeons,” he admits. “Often, we have strong feelings about equipment needs and surgical techniques, such as those related to incision size. Although surgeons are often loathe to change technique, you can encourage an open approach by pointing to the enormous changes in cataract surgery during the past few decades. Most changes in surgical packs are miniscule compared to these major shifts in practice.”

Tracy Rhodes, RN, BSN, the ASC Director of Nursing at the Eye Center of North Florida, says the surgeons at the center use virtually the same pack. “The only exception is the drape,” she says. “One surgeon prefers aperture, while the other uses an incise drape.”

Agreement on basic items lets the Eye Center of North Florida buy in bulk from suppliers and negotiate a better price, says Dr. Fisher. “Any of the more expensive items, such as phaco and I/A tips, are extremely important to agree on whenever possible. The price for purchasing one of these as a stand-alone item is about twice the price of the item when it is included in a pack.”

Dr. Bizer says cost should also be balanced with surgeons’ needs. “Keeping a group of surgeons happy and comfortable with the supplies is more important than saving a few bucks,” he says. His ASC has 14 anterior segment surgeons and four retinal surgeons. “We have the common pack for the anterior segment surgeons and we supplement as needed,” he says. “We have a different basic pack for retina.”

Working With Manufacturers

One myth is that not all companies want to work with ASCs. “Pack companies really want your business and will work very hard to be competitive with pricing,” says Dr. Aker. “You should provide estimated numbers of surgical cases 6 to 12 months in advance. This allows the company to auto-ship customized packs to you. The higher your volume, the better the pack price will be.”

Dr. Fisher says his center recently added a “sister pack” to its standard pack. “It containts BSS Plus, an alternate viscoelastic, and another hydrodissection cannula,” he says. “This pack ships out in place of my standard pack every other week. It allows us to purchase a more expensive viscoelastic at about half the price by placing it in a pack. We then have the product on hand, and it’s delivered on a regular schedule so we aren’t constantly checking to see if there’s stock on hand when it’s needed.”

Dr. Fisher includes the following in his pack: Alcon 0.9 mm ABS mini 45 Kelman phaco tip, Alcon 0.3 mm curved polymer I/A tip, 27g hydrodissection cannula, 25g reverse cut cystotome, 30g capsule polisher, eye spears, cotton applicator, suture bag, instrument-soaking bowl, specimen cup for securing sharps, gown, drape, sheet, Nu gauze sponge, medication syringes, instrument wipe, standard prep kit, incise drape, Balanced Salt Solution (500cc and 15cc), viscoelastic and 5% povidine-iodine prep. Dr. Tipperman’s current pack includes a keratome,

“Our ideal custom pack has no unused products at the end of the case and a happy circulator who hasn’t opened a single additional sterile product,” says Sue Smith, RN, Dr. Aker’s nursing supervisor. The pack at the Aker Kasten Surgery Center also contains sterile components selected because of cost, including gowns, gloves, paper (instead of cloth) hand towels and a patient drape. “Companies formulate packs the way you want them because they really want your business,” says Dr. Aker.

Janet Nuzzi, RN, the senior OR nurse at Aker Kasten, suggests you avoid the temptation to bundle a pack with a company’s viscoelastic or IOL to get a better price on the pack. “On the surface, this may appear advantageous, but it ends up limiting your options,” she notes. “The lines become very blurred on how much you’re actually spending on each product in your pack because they’re locked to a specific viscoelastic, IOL or balanced salt solution.”

No More Assembly Lines

No matter how you customize your packs, the best approach is to evaluate your choices, surgeons and their assistants say.

“In the past, we had an ‘assembly line’ of two employees working to see that everything was pulled for the day’s cases and opening each individual component for each case,” reflects Dr. Fisher. “At the end of the day, I used to hear, ‘But we still have to pull cases for tomorrow.’ Now I hear: ‘Cases are pulled for the week.’” ◊