When outfitting an OR for total joints, you want to standardize the room and streamline its contents as much as possible. This means designing and furnishing each OR identically, from the X-ray risers on the OR tables, to the positioning equipment that you store in each suite, to the suture and the saw blades, to the tables that can twist and turn every which way. This means convincing your surgeons to decrease the number of total joint instrument pans and to agree on the contents of the procedure packs. It also means having enough staff and instruments to turn rooms over in a timely fashion. Your reward for such well-kept rooms will be greatly improved efficiency, significant savings and satisfied surgeons.

When we opened the Virtua Joint Replacement Institute in August 2012, it was a marriage of megatrends: new surgical construction unites with the budding popularity of same-day joint replacement surgery. More than 3 years later, we're still in our honeymoon phase. In 2015, we did exceptionally well: We replaced more than 2,000 joints in our 6 ORs.

Much of our success lies in our room design, the smart equipment purchases we've made, and our efforts to keep our instrument and supply inventories as minimal as possible. The fewer items you have on the shelves and the fewer supplies you have to pick, the easier it is to prep a case.

Form and function
We built our facility from the ground up. In addition to the perioperative space, we constructed a central sterilization department, 30 inpatient beds and a rehab gym. On average, our hip and knee replacement patients' stay is 1.3 days before discharge. From top to bottom at our facility, standardization leads to efficiency.

We relied on the expertise of our 6 surgeons and our orthopedic-trained nursing staff to build our facility. We worked with our surgeons not only on the grand facility design, but also solicited their input on how to furnish the rooms. The OR and central sterile and supply department collaborated on the design of our case carts, down to which shelf instruments will go on. You can look at any case cart and know at once if something is missing. Our central sterile staff even had input on how they wanted instruments reloaded onto a dirty case cart.

All surgeons, of course, have a lengthy list of equipment, instruments and supplies that they prefer. Our job was to reach a consensus on big-ticket items like OR tables and streamline wherever possible when it comes to disposables.

Between our hip and knee replacements, we started with 4 custom packs that had all of the case consumables, such items as drapes for the back tables and Mayo stands, patient drapes, lap sponges, blades and the Bovie pencil. We're now down to 1 pack. Once we did our first few cases, we modified the packs accordingly, adding or removing items as appropriate. Our rule-of-thumb that guides us to this day: If we use an item more than 60% of the time, it stays in the custom pack.

We soon found out which items we were routinely wasting and were able to prune our packs, one item at a time. Take dressings, for example. One of our surgeons was using 2 Ace bandages, another was using just 1. We had 2 Ace bandages in our packs, so we were just as often throwing 1 out as using it. So we removed 1 Ace bandage from our packs and pulled a second one separately for the surgeon who prefers to double up on dressings. (Note: This surgeon uses the second Ace bandage in a non-sterile fashion, so it's not necessary to keep it in a sterile pack.)

We also eliminated suction tubing from our packs, and we reduced the number of lap sponges from 20 to 15 (most patients are under a tourniquet, so we didn't need that many). When you remove items from your packs, you have to sit down with your doctors and convince them to give the change a chance, and then clearly communicate the changes to your nurses. You also need to keep preferences cards current to reflect items eliminated from packs that will need to be picked separately.

About 80% of the contents of our packs are standard. The rest we call "idiosyncrasies" — items specific to each doctor that we pull separately, including suture, saw blades and surgical blades (some like them bigger, some like them smaller).

The benefit of streamlined packs is huge. Not only will it decrease the amount of inventory and storage space you need, but it'll also lessen the amount of waste you produce — once you open something, you have to throw it out — and the time it takes for your nurses to pick for cases.

We also streamlined the number of instruments that we use in a case. It's been said that a typical total joint case has an average of 120 items on a preference card. We got ours down into the 80s by standardizing what our docs use and keeping our surgeons' preference cards accurate and up to date.

We took our instrument trays down to a minimum as well. A typical total knee set contains about 8 instrument trays. Working with our vendors and docs, we were able to bring that down to 4. We simply eliminated those instruments that our docs didn't use. When you drill down deeply enough into your sets, your surgeons will say, "I don't really use it" or "I know it's on my tray, but I don't really need it." Our central sterilization department also benefited from us having fewer instruments on fewer trays. Not only did they have fewer items to clean, but they became experts at reprocessing the items on our trays. Our trays are impeccable. It's not uncommon for bone cement or bone chips to be left on instruments that aren't properly cleaned. Ours are always in tip-top shape.

Self-sufficient ORs
Our total joint ORs are self-sufficient. Once you're in the room, there's little reason you'll have to leave to retrieve something. A good example of this is that we stock each OR with all the positioning equipment our surgeons and staff need: leg holders, leg positioners, rolls and pillows. These items never leave the room. We store some on a small cart and some in a supply closet in the OR, and hang others on hooks and on the rail of a supply cart. This cuts traffic going in and out of the room, which is especially important with joint replacement surgery. Numerous studies have shown that door openings disrupt the laminar air flow and increase the bacterial count in the operating room.

Your surgeons' preferences impact what you'll need in the room. Some of our docs don't like the X-ray riser on the OR table. Depending on whether the X-ray riser is on or off, you'll need a different sized armboard pad. We keep different size pads in each OR so we can quickly accommodate each surgeon and ensure the comfort and safety of our patients. For total knees, an X-ray riser adds a couple inches to the OR table. Some like that added height, some don't. If you take the X-ray riser off, the armboard pad needs to be about 2 inches thick. When the table has a riser, the height of the armboard pad is about 4 inches.

The centerpiece of the room
Of course, the most important piece of equipment in a total joint room is the OR table. Be sure to ask your surgeons for their input on the features they want in a table and arrange for a hands-on trial with vendors. For total hips, they want a table that elevates to their eye level (yes, it needs to rise pretty high!). It also needs to slide. A hydraulic sliding table allows the foot of the table to be free of the base so you can slide a C-arm under it for the anterior-lateral approach to the hip joint.

Pay close attention to the firmness of the table pads. Your docs will want a firm pad so that the patient's foot doesn't sink too far down during knee surgery.

We use tourniquets for our total knees. Our tourniquets let us change the time and pressure while the tourniquet is still inflated. The tourniquets also integrate to the OR record so we can track things electronically.

When we opened, the staff was used to using 2 very large, long back tables to hold our instruments in each OR, but we found the tables took up too much space. We improvised. We have a "drill" table that bellies right up to OR table. It's about a 3-foot by 3-foot square table that's very convenient to have in the sterile field to work off of. It's compact for our sterile field set-up. The scrub tech uses it like a Mayo stand. We call it the "drill" table to distinguish it from a second larger back table.

Cost-conscious
Each month we share cost-per-case data with all of our surgeons. We break down how much each doc spent on implants and disposables. The very act of bringing awareness to what things cost makes us all more cost-conscious. If something's truly valuable, let's use it. But if there's an alternative that's just as good and costs less, let's go with that. OSM