READY TO ROLL An assembly-line process is ideal for a cart system, but can your facility accommodate that?

Case carts aren't flashy technology, but they're key to getting the right instruments to the right place at the right time. And choosing a cart system without acknowledging the huge role it plays in your workflow can be a costly lesson, believe me. I once managed a purchase that inspired an AORN poster titled "How Not to Implement a Case Cart System" (osmag.net/r7NHZc).

If you think about case carts at all, you probably see them as a convenient solution for transporting surgical supplies to the OR. While that use certainly keeps your staff from having to haul armloads of trays down the corridor themselves, carts also address infection prevention and quality care concerns.

Case carts help to safeguard the sterile integrity of surgical instruments and supplies until they're ready for use in a procedure. They accomplish this largely by limiting the movement of the items that are pulled for a case. Removing items from the supply room shelf and placing them right into a mobile cart that's taken directly to the OR reduces the number of times those items are touched, handled or moved during case preparations, as well as the number of opportunities to damage or contaminate blue-wrapped instruments or packaged supplies. A closed cart system that stores items behind doors adds another layer of protection.

Carts also safeguard the passage of used instruments on their way to the sterile processing department after surgery. Contaminated instruments can contaminate your environment, but containing them in a closed cart or at least covering them on an open one can prevent the scatter of debris while they're in transit. In the course of my 30-plus years in surgery, I've worked at facilities where used instruments and supplies were stacked on top of OR tables after surgery, covered with drapes and wheeled to central sterile, so it goes without saying that carts enable much cleaner and more efficient turnovers.

Contained transport also keeps the remnants of surgery out of sight for patients and their families. You really want to protect them from seeing dirty, bloody or contaminated things, and if the corridor through which you move them happens to pass by the PACU, they're a captive audience to such behind-the-scenes work.

The importance of input
Considering the advantages it offers your perioperative process, you might think that implementing a case cart system would be a simple transition for your OR and sterile processing department. "What's the big deal?" you're asking. "If it's got 4 wheels and shelves, let's buy it and put it to work."

Hold on there. Have you asked the staff whose work will be affected by these carts what they think of your choice? Even an overlooked piece of equipment can have a major impact on "the way we've always done things," and as with any equipment purchase, pushing a change out to end users without their buy-in can be a costly and demanding effort for a manager and her facility. Every now and then you hear about how a big budget item that was supposed to improve a facility's workflow is now abandoned and gathering dust in storage. You wonder, "What were they thinking?" The answer is, they didn't ask what others were thinking.

Unless you're running your facility as a dictatorship, seek input from everyone. Build a committee made up not just of managers, but also of OR nurses and techs, sterile processing techs, even housekeepers. You have to have the front-line staff on board, because they're the ones who are going to be loading, pushing, unloading and washing the carts. Without their voices of approval, implementation won't be easy.

PICK UP THE PIECES Who's in charge of maintaining your cart system? Is that efficient?

Making carts work for you
There's a lot of preparation in a day's caseload. Ideally, you're aiming for some sort of assembly-line flow to keep supplies moving and organized. The case carts you choose can make a big difference in how productively your staff is able to set up a case.

First of all, you need to know your workflow. How many ORs do you have going at the same time? How many cases do you see in a day? You'll need more than 1 cart per room, and possibly 3 per room: 1 serving the case that's in the OR, 1 being washed in central sterile and 1 being filled for the next case.

Does the day's schedule consists of a few major cases or many minor ones? This can determine which size of cart would be most efficient to use. Or, since smaller cases may only require a small tray of instruments and minimal supplies, you could organize the needs of the next several cases into a tall cart parked outside the OR door and ready to go. If you're buying multiple carts, mixing and matching large and small carts is not unheard of.

While open cart styles make it easy to see and gain access to a cart's contents, the doors on closed models add security, especially if they lock, by preventing the supplies and instruments pulled for a case from being swiped for use in other cases. With either model, make sure that the shelves have no sharp edges that can tear blue-wrapped packages.

Put through the paces
Test-driving case carts through the traffic patterns they'll face every day in your facility is extremely important. Here's something that even a hands-on trial at the manufacturer's showroom won't tell you: that a cart doesn't fit through the central core doorways at your facility. (The one we chose missed by a quarter of an inch. It fit when we removed the bumper, but that defeated the purpose of protecting doors, walls and fingers that got too close to either.)

Ergonomically speaking, your case carts should be something that your staff can easily work with. Their weight is of course a big concern, but so is their height. A nurse who's 5 feet tall won't be able to see over the 5-foot cart she's attempting to navigate down the hallway. There is an argument to be made, however, that it's easier on the back to retrieve a heavy tray of orthopedic instruments from a higher shelf than it is to lift it from a crouching posture.

A cart should be cooperative in its maneuverability. The wheels shouldn't put up a fight when you're pushing them down the hall or around a corner, and they should feature locks or brakes to keep them where they're parked.

Speaking of parking: How much space does your facility have to accommodate carts' OR use, reprocessing and between-case storage? Cart size also factors in here. The footprints of tall carts, more vertical than horizontal, economize on floor space. Shorter, wider carts, on the other hand, can double as tabletops on which to set up cases. Ideally, implementing a case cart system will also include budgeting space for a cart washer, which is much more efficient timewise than manually disinfecting them.

The people behind the process
The investment of time and money into a new fleet of case carts may be a worthwhile occasion to reconsider how they're used, particularly in terms of which department will be maintaining the system by pulling the cases and pushing the carts to the OR.

Some facilities are making a move toward assigning the task to their sterile processing techs. This makes a lot of sense for 2 reasons. First, anyone can read the menu of a surgeon's preference card, and the SPD is less expensive labor. Where would you rather spend your nurse staffing dollars: on nursing, or on picking supplies? Second, most sterile processing techs know the names of instruments better than OR nurses and scrub techs do. Partner your OR staff with your SPD staff on case carts — for which, of course, both parties' input is critical — and smooth the flow of your instruments and supplies.