On a recent vacation, I went out to eat at a small, out-of-the-way restaurant we always visit on our trips to the Outer Banks.
There, I spotted a poster on the wall explaining why the cafe no longer uses plastic bags or plastic straws: to keep the material out of the ocean where it never really goes away.
Plastic bags, straws, eating utensils, plates, bowls, and cups are everywhere in hospitals these days. They sure make things convenient, one-time use … throw away. I am sure they also cost less, which is a big reason hospitals use them. Having said that, I know many of us can remember when stainless steel flatware, real coffee cups, and solid plates were part of the hospital eating experience. The transition from reusable eating utensils, cups, and plates in hospitals to single-use plastics may be cheap and convenient but at what cost to the environment?
So much has changed in materials used in surgery, too. The creation of the sterile field used to be done with linen towels and sheets which had been carefully laundered, sterilized, folded precisely and packaged. Today, that’s been replaced with paper drapes which are used one time and discarded.
Needles for placing sutures used to be reused. Scrub nurses were known for how quickly they could place sutures through needle eyes and how well they protected these important instruments. Now the sutures all come prepackaged with the sutures already attached. Also, all laparoscopic instruments and surgical staples are used one time and thrown away.
The latest push for one-time use is lighted retractors. I have personally always used a headlight to see into dark, poorly lit places in the human body, but many of my colleagues use a retractor with a light on the end of it. These are attached to a light source of the sterile field. In the next few years, it seems we may all be using battery-powered versions of these tools, to be discarded after each use (for sure, salespeople from several large medical device companies are preaching their advantages).
The point of all this is not to lament the good old days. Rather we should think about the vast amount of waste that exists in modern medical care today. From cafeterias to med surgery units to operating rooms to the administration of hospitals, practices and insurance companies — waste is everywhere. If we could eliminate the majority of this waste, we would have enough resources for all of us to have the high-quality care we need and want.
One former colleague absolutely hated waste. He would use a suture until there was less than a centimeter left on the needle before asking for a new one. Nurses in every operating room knew this and talked about it. No sutures were opened until he asked for them. Contrast this with the practice of opening many sutures before an operation to be sure the surgeon will have what he or she wants immediately. Then if something is not used, it is discarded.
Aside from hospital cafeterias and medical supplies, waste also exists in the administrative processes involved with medical care at all levels. Every private practice and health care system has a large group of employees who do not deal with the direct delivery of care.
In my mid-sized practice, we have one full-time employee whose entire job is to pre-certify procedures for our insurance patients, three full-time employees who send the bills and deal with the insurance companies after we have given care, and a full-time employee who manages our accounts payable and payroll — in addition to an office manager. I’m certain this is a drop in the bucket compared to massive health systems. On top of this, think about all the people who work at insurance companies, whose entire business is based on being a pass-through for money from employers and people to health care providers. Add Medicare and Medicaid, and government programs that do the same thing … it’s no wonder health care spending seems to be out of control.
So, what’s to be done? Some advocate for a single-payer system, arguing that this would simplify payment and allow more control of spending. Time — and politics — will tell if that works out.
For now, I think we start in our own daily walk. Be mindful of waste. If you are a surgeon, use that suture down to the last centimeter. If you are a nurse, work on ways to save supplies on your unit. If you are a hospital administrator, think about how you can begin to lead your organization toward a culture of sustainability.
Sustainability is a big deal in many places today, but it seems not to have taken hold yet in health care. I think we need to catch up to be better stewards of our resources. Maybe, that will improve how we deliver care.
Isaac L. Wornom is a plastic surgeon and editor, Richmond Academy of Medicine’s Ramifications newsletter.
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