When a case calls for fluid waste management, surgical administrators and staffers alike swear by direct-to-drain disposal systems. These closed suction devices collect and drain fluid without the need for manually handling suction canisters. To those who've made the upgrade, there's no going back to dumping or solidifying. It can be expensive, though. Does it make sense to invest? See what our experts have to say.

Counting the costs
The simplest way to determine whether to install a direct-to-drain system or continue to rely on manual disposal is by calculating cost efficiency.

There are 2 types of direct-to-drain suction and disposal equipment:

• Wheeled, portable units. These roll from room to room and to drainage ports for automated emptying. Equipment planners estimate the average list price of a mobile unit at about $22,000.
• Wall-mounted, stationary units. These permanent fixtures, plumbed directly to the sewer, never need to be emptied. List prices can range from $6,000 to $17,000 per room.

In addition to the initial costs, purchasers of closed systems must also budget for the installation of the plumbing required to send fluid waste to the sewer. This cost will vary from facility to facility and from situation to situation. While wall-mounted units are plumbed directly to drainage pipes, mobile units need a docking station to facilitate discharge.

Plus, the use of some direct-to-drain systems entails continuing costs of disposable components. Single-use filters, which protect the suction intake apparatus and patient against contaminants in the fluid that the equipment has collected, are changed between each case. They cost $10 to $15 each. Some products automatically disinfect themselves after they drain, a function that requires enzymatic cleaning solution. A 2.5 gallon jug, which a high-volume orthopedic surgery center says lasts more than a month, costs $100.

Planning ahead with a service contract adds another cost variable, but is often recommended, especially for mobile units. "It's mechanical and it's electrical. It's got a pump and wheels. Any time you have those types of parts, something can malfunction," says Stuart Katz, MBA, FACHE, CASC, executive director of the Tucson Orthopaedic Surgery Center in Tucson, Ariz. "Routine preventive maintenance can help to prevent that. We have [a bioservices tech] come in and look at it every 6 months. Does it cost us a little bit more? Probably, in terms of actual expenses, because maybe something's not broken. But it also means that we're not without it, which would slow up our cases."

The costs associated with direct-to-drain can be significant, but there are deals to be had depending on your facility's relationship with the vendor and whether it participates in a group purchasing organization. "Everything is negotiable," says Lynne Ingle, RN, MHA, CNOR, a medical equipment planner for Gene Burton & Associates' Ontario, Calif., office. For instance, she says, if a system's manufacturer also offers medical devices outside of the fluid management field — and if your facility has a history of purchasing those offerings — you may be able to net steep discounts on the price of the equipment, especially if it involves regular orders of disposable items. "No matter what product you look at, it's the disposables that's where the business is," she says.

Mr. Katz notes that he negotiated the cost of his mobile units' disposables into the service package. At the Boston Out-Patient Surgical Suites in Waltham, Mass., they even financed the purchase of a mobile unit through the purchase of its filters. "We took the price of the equipment, divided it by our case volume, and added that amount" — about a dollar extra — "to the cost of the filters we'd buy," explains Greg DeConciliis, PA-C, CASC, the center's administrator. This arrangement ended up paying for the machine in about a year and a half, he says.

Factoring in the fluid
In comparison to the capital outlay for direct-to-drain, the costs involved in manual fluid waste disposal may seem like a thriftier option. After the suction deposits fluid into a canister (about $4 to $8 for a 3-liter container), the canister is transported by hand or on a cart to the disposal area, emptied into a utility sink and discarded. Or, a chemical solidifying agent ($2 or $3 per bottle) is added and the canister and solidified fluid are discarded with the facility's biohazardous waste (the disposal costs of which vary by hauler).

A mechanically simpler solution, perhaps, but how much does dumping or solidifying really cost you? If your ORs mainly host such low-fluid cases as endoscopy, ophthalmic surgery, ENT and podiatry, its costs are in your favor. But if your case mix is weighted toward orthopedics, or includes fluid-intensive general, urology or GYN procedures, the simpler solution may cost you more than you think.

"Each canister is associated with a cost," says Mr. DeConciliis. "Not only do you have to keep buying a ton of canisters, you have to stock them somewhere." Surgeons doing shoulder arthroscopies and anterior cruciate ligament repairs can be counted on to use multiple 3-liter bags of saline in a case, and as a result require multiple 3-liter canisters to collect the used fluid. "If a case uses 10 canisters, you're down at least $40," he says.

If the canisters you buy are not designed to be disinfected and reused, that money is just going out with your red bag waste. What's more, if you're solidifying the fluid in the canisters, you're making the red bags heavier and more expensive to cart out.

"For any operation that uses a lot of fluid, you need to look at what's the best method for collecting the fluid and disposing of it," says Mr. Katz. "I can guarantee you that if you use more than a few canisters per case and throw them away, that'll cost you more money than a closed system would."

To get a rough estimate of costs for your facility, he says, take the number of canisters used in an average day or week and multiply that by the cost of each. If you solidify, add in the cost of the agent used (keeping in mind, he notes, that 3-liter canisters tend to need 2 bottles of solidifier to do the job). "Look at it this way," says Mr. Katz. "If you spend $100 a day on canisters and solidifiers for 1 OR, it won't be very long before you've basically bought yourself a [mobile fluid disposal unit]."

Additional advantages
Case-costing is a major factor in deciding on a fluid management method, but saving money isn't the only benefit you stand to gain. Direct-to-drain disposal comes out ahead of risky and time-consuming manual disposal in work efficiency and safety.

"Efficiency is where we put our money," says Mr. DeConciliis, whose surgery center sees 300 to 350 orthopedic procedures each month. He says the need for his facility to switch from dumping to closed drainage became apparent when canisters piling up during cases impacted staff workflow. "Some took 10 or 12 or 15 canisters for a case. I think 20 canisters was our record."

The time it takes to repeatedly replace full canisters with empty ones and manually dump or solidify the contents detours your highly trained nurses and techs from the tasks you're paying them for, he says. Changing canisters might also interrupt procedures and surgeons, since it requires that suction be temporarily disconnected, something that closed systems with more capacity can eliminate or reduce.

Can you put a price on safety? With fluid waste management, the potential costs of manual disposal are clear. Full 3-liter canisters can weigh 7 to 10 pounds, and carrying them can present an ergonomic hazard. Opening their lids to dump or solidify can result in spills or splashes. With closed systems, says Ms. Ingle, "the reality is you're looking at safety, less exposure for your employees to biohazardous waste and to back injuries."

The federal Occupational Safety and Health Administration's rules for regulated medical waste include the warning that "employees should not open, empty, or clean containers in a manner that would expose them to injury." While gowned, gloved, masked and face-shielded employees can dump fluid wastes safely, the potential costs of medical treatment, workers' compensation and litigation may make administrators think twice. "Any risk manager will tell you to limit your staff's exposure," says Mr. Katz. "Fluid waste is an exposure to my staff that I don't wish to get into."

Thinking of buying
If you're considering a direct-to-drain system, one of the first decisions you'll have to make is between wall-mounted or mobile equipment.

Since stationary, wall-mounted units are plumbed directly into drainage infrastructure, they're essentially unlimited in their capacity and don't have to be emptied between cases, says Mr. DeConciliis. They don't require bringing additional equipment to and from the OR, and for rooms that consistently require fluid cleanup, they're always on hand.

As a consequence, however, their installation may require renovation and their permanence may limit mobility in a room. "How far does its tubing extend?" asks Mr. Katz. "If extra tubing is needed, will that create a trip hazard?" Ms. Ingle also points out that fixed equipment might not lend itself to half-measures. "If you don't put one in every room, can you still function?" she asks.

Unless your caseload's need for fluid disposal is extreme, you don't need to buy a mobile disposal unit for each room. You'll have to make some case-volume-based estimates, however, to decide how many to share. A mobile system's portability gives you more flexibility — "It's easy for staff to position for the case at hand," says Mr. Katz — but it does require draining, which means installing at least 1 docking station plumbed into a sewer line.

This raises room space issues, says Ms. Ingle. "Where do you put the docking station?" she asks. While the decontamination room seems an obvious choice, would it interrupt reprocessing workflow? Perhaps an environmental services room or utility closet closer to the OR would be more efficient, depending on how your facility operates. "How does your process flow? When staff are done with a case, how do you manage dirty linens, disposables and other wastes?" Also, she notes, can the mobile unit be easily maneuvered through doors and around corners to fit where it needs to go?

Choosing a product whose capacity exceeds that of the fluid used during a case is critical, says Mr. DeConciliis. Your staff may not be able to empty a mobile unit just once at the end of the day, he says, but you'll want to avoid making them wheel it out of the OR to drain in mid-case.

Suction systems that connect to surgical instruments, floor vacuums and fluid pouches on drapes provide efficient fluid collection, but be sure to test the strength of the vacuum pressure, says Ms. Ingle, especially if multiple suction ports are in use simultaneously or if several wall-mounted units in adjoining rooms are being used at the same time.

Above all, seek quality. How reliably does the system work? How reliable is the availability of service? "This is not a disposable system you're buying. You're going to be with this for a while," says Mr. Katz. "Buy at or near the top of the line, and they'll pay for themselves."