Economics and Efficiency
You can make a big deal out of the little things that add up.
Dr. Chang: Can we talk a little bit about the economics of getting a new system into our hospitals? With the development of the Constellation, I think Alcon has looked at our ability to improve our surgical efficiency. The company has developed a system of features called V-Locity Efficiency Components. Dr. Williams, could you talk about how these features might improve your surgical efficiency in the operating room?
|[Time] is the one resource that we can control. Labor represents 75% of our costs, while disposables are about 3%. Yet people make this point about disposable instruments costing more money. The real costs are related to labor.|
— Steve Charles, MD
Dr. Williams: I think this technology has the potential to address an increasingly important issue: the difficult reimbursement market. In this market, we need to maximize our efficiency as surgeons. We want to be able to complete every case in as expedient a manner as possible, in the safest manner possible, and in a manner that frees up the one resource that we can control — our time.
Any technology that improves efficiency by even 10% or 20% should translate into financial advantages both for the surgeon and the institution. One of the aspects of the Constellation technology that strikes me as very helpful is the user-friendliness that I have seen, particularly the ability of the machine to facilitate its own set-up. It will be nice to have a system that individuals can operate relatively effectively, even if they have not been fully trained to use it.
The Constellation also will be able to be set up much more efficiently. The use of the Articulating Tray Arm will allow the scrub personnel to prepare for the case before the patient enters the room to be prepped and draped.
This strikes me as a big advantage in facilitating turnover time as well. The fact that the system sets up in less than 2 minutes creates extra time in your schedule that adds up over the course of a busy day. I think we must stress to the leaders of our institutions that this technology can make their staffs more efficient. It is going to decrease the incidence of a common problem in my institution. I hear people say, "Well, we do not really have anyone from the ‘eye team’ available to do your case right now, so here is the urology nurse." The nurse they provide does not have a clue as to what is going on. Any care delivery system that enhances efficiency is going to offer substantial advantages.
Dr. Charles: We use the word "efficiency" and clearly it is the appropriate word, but let's define it a little more specifically in the sense that we're talking about time. As stated previously, it is the one resource we can control. Labor represents 75% of our costs, while disposables are about 3%. Yet people make this point about disposable instruments costing more money. The real costs are related to labor.
It took the hospital systems — and they are still transitioning in this area — a long time to learn how best to use highly trained, hourly nurses. There is a juncture at about 3 p.m. when either you pay time-and-a-half so the surgeon can do cases until 5 p.m., or you bring on a new team who, if they are any good at all, do not want to work 2 hours and then quit.
So when you look at the feature set, you have a barcode reader and the Engauge RFID, which take the documentation costs and costs associated with downtime to zero. You have an efficient set-up process because it uses Push-Prime, with a tubing management system, and the Articulating Tray Arm can be prepared while the patient is being prepped and draped. All of these things are going on at the same time, instead of serially.
At the end of the case, the clean-up and turnover situation improves as well, because you have the End Case Reporting function. It does everything you need for an Op note except what you observe clinically. It keeps track of all the steps you have taken, all the parameters and metrics. It keeps track of all the supplies that you have used with a combination RFID and barcode reader. It also can help you produce a pick list for the next case. If you say, "I liked how we did that, and everything we used," you can store that information or print it on a wirelessly connected printer. Then you have a step-by-step list that you can follow the next time.
PROTECTING AGAINST WASTE
Dr. Packo: The system is very good about protecting against waste. It does not take much waste in the operating room to kill your DRG allocation that Medicare pays for the procedure. In the evolution of our surgical technique, we have all been guilty of opening this and opening that. We use this probe for a little while, then decide we want another laser probe. You realize you start opening up $150 probe after $150 probe.
You go to a second bottle for infusion. It is much more money for a second bottle of BSS-Plus. And the other significant factor: If you do not get the gas to the table correctly and it is left hissing, you are expelling gas out of a $1000 tank. You can run through money quickly.
I think another cost-savings to the hospital, with this new technology, is not only time efficiency for the personnel and set-up but also having a system that tries to minimize your waste and that tracks usage. The barcodes instantly tell you what you have. The reader populates the machine with all of the parameters. You have one multifunction probe and a lighted laser probe that you can use for everything. And even though you have the consumable costs, in the big picture, you are not opening many things. You are controlling what you are using. I think you are cutting down ultimately on waste over the course of the year.
Dr. Charles: You made the point about disposable tools. If you look at pro forma costs — the labor costs associated with cleaning them properly and then sterilizing them, packing, storing and retrieving, and having back-ups for reusable instruments — it's simply not economical in any part of the world. There is always an assignable per-case cost.
On the subject of cleaning, I have great concern. I know Dr. Flynn has done a great deal of work in this area. TASS — Toxic Anterior Segment Syndrome — was shown to be due to enzymatic materials, bio-burden or other residual materials in the lumens of cannulas and other tools used in cataract surgery. The cannulas went through an ultrasonic cleaner, which uses enzymes produced by bacteria. Even though the cleaner was sterile, those enzymes were biological materials that created inflammation. They were not just toxic chemical materials.
All of these materials can be retained within lumens. We know vitreous cutters have lumens, but so do scissors and forceps. That is how the shaft moves up and down. It is virtually impossible to clean, and the smaller the instrument, the more difficult it is to clean, which is why safety is increased with disposable DSP forceps and scissors, as well as cutters and other disposables.
I think much of what we used to call fibrin syndrome in the back of the eye was really toxic posterior segment syndrome caused by inflammatory materials inside the lumens of the scissors, forceps and cannulas that we reused. In my opinion, it is a false economic benefit and unsafe to reuse tools.
FEATURES THAT ADD SAFETY
Dr. Chang: In addition to speed and efficiency, safety is certainly an important factor. The Constellation platform promotes safety by signaling when the infusion is running low, allowing us to change bottles without clamping the line. The machine also features auto-gas fill, which saves time and is much more accurate than a circulator in the operating room or an inexperienced assistant.
Dr. Flynn: For the auto-gas fill, there is no stop-cock to be left open, which in the past could result in draining the tank.
Dr. Chang: I think there are some important safety features that are going to make our procedures safer. RP