Problem

At our institution, there are currently two orthopaedic hand surgeons who together will conduct in the region of 500 carpal tunnel decompression (CTD) procedures each year in the day surgery unit. The surgical technique used is a standard open approach for decompression of the median nerve. The practice prior to our analysis involved CTD to be performed under a local anaesthetic of 10–15 mL of 0.5% Chirocaine using a disposable tourniquet to aid in a blood-free surgical field. Standard operative time is approximately 7–10 min.

Given the prevalence of carpal tunnel syndrome (CTS) and the high number of CTD procedures conducted at our establishment we decided to analyse our practice to establish areas where costs could be minimised while still preserving quality of patient care and safety. Our study was conducted over a 6-month period and resulting changes have now become standard practice.

Background

The National Health Service (NHS) net deficit for the 2015/2016 financial year was £1.851 billion according to NHS Confederation with a continued projected increase in total spending going forward.1 The NHS is struggling against an increasingly ageing population to manage financial balance and is operating consistently at a significant loss. As individual establishments, it is up to each hospital to look at how savings can be made across services while maintaining the quality and safety of care provided to their patients. As individual surgeons, it is also up to us to look at our own practice and establish areas where such improvements can be made.

CTS is the most common form of nerve entrapment in the upper limb, occurring when the median nerve is compressed at the level of the wrist within the carpal tunnel. In the UK, 88 men and 193 women present to their general practitioner as new cases per 100 000 population.2 Of these patients, 43–74 per 100 000 will go on to require a surgical decompression.3 There are currently around 53 000 decompression procedures undertaken in secondary care each year.4 CTD is extremely effective in reducing CTS with success rates as high as 90% in randomised trials.5 6

Baseline measurement

By working with the procurement department, a detailed investigation of costings for the expendables used during a CTD was undertaken based on the standard surgical practice at our institution. The total costings of expendables worked out to be £49.60. The majority of this total cost consisted of instrument sterilisation costs for a full orthopaedic hand set (£23.58), a disposable tourniquet (£10.20) and a large hand drape (£6.67). A complete summary of costs is shown in table 1.

Design

To establish how cost savings could be achieved, a meeting between the two hand surgeons and all theatre personnel involved in performing CTD procedures at our institution was held. We systematically broke down the procedure into individual steps, critically analysing the consumables used. Once a complete list of consumables and costs had been established and attributed to each individual stage of the procedure, each step was appraised for potential improved alternatives based around a comprehensive review of the current literature to ensure that any changes proposed were evidence based and afforded a safe and effective alternative.

Wide-awake, local anaesthesia, no tourniquet (WALANT) hand surgery is a concept that has been showing increasing popularity among institutions worldwide. The use of a local anaesthetic with epinephrine for surgery involving the hand and wrist has been demonstrated by several studies to provide excellent haemostasis, negating the standard use of a tourniquet to provide a bloodless operative field with the added benefit of removing the associated tourniquet pain.7–9 Although the use of local anaesthetic with epinephrine has traditionally been discouraged in the hand due to perceived risk of digital ischaemia, review of the literature amounting to over 4000 patients receiving injections of epinephrine into the hand or fingers did not demonstrate any ischaemic complications, suggesting that such practice is safe.9 From the cost saving perspective, a recent study by Rhee et al examining the cost savings and patient experience of WALANT hand surgery in the clinic setting at a military medical centre in the USA demonstrates considerable cost savings as well as a high level of patient satisfaction.10 This study further backs up the findings by Leblanc et al in the Canadian healthcare system, which also demonstrated the cost savings and safety of WALANT surgery, again in the clinic setting.11 Currently, there is no similar analysis of WALANT surgery for carpal tunnel and other hand procedures in the UK.

How patients are draped for a surgical procedure can also result in substantial differences in cost. When considering minor hand surgical procedures there is evidence supporting the effectiveness of field sterility, where only the hand being operated on is prepped and draped, as opposed to full operating theatre sterility necessitating the whole patient to be covered. Leblanc et al prospectively examined a cohort of over 1500 patients who underwent carpal tunnel surgery in minor procedure rooms using field sterility with the surgeons only wearing gloves and a mask and not full theatre gowns. The results of their study demonstrate a 0.4% superficial infection rate with 0 deep infection.12 A systematic review by Jagodzinski et al analysed surgical site infection after hand surgery carried out in a clinic setting. This study demonstrated that minor hand surgery could be performed outside the operating theatre using field sterility, without increasing the risk of infection.13 It is important to consider that in the current set-up within our establishment, procedures are carried out within the operating theatre as opposed to a minor procedure room or clinic room setting such as in the studies described.

Strategy

Based on the costings established and the literature review several areas for change were highlighted that would offer significant and safe cost savings. First, changing the type of local anaesthetic used to Xylocaine with adrenalin instead of using 0.5% Chirocaine. The Xylocaine plus epinephrine local anaesthetic would still produce a good quality of anaesthesia but also deliver a haemostatic effect via localised vasoconstriction. This change in type of anaesthesia would also negate the need for a disposable tourniquet. Both these changes would convey a cost saving and the patient would benefit from not having the discomfort of the tourniquet pressure throughout the procedure.

The significant cost of the drapes being used was also highlighted by our analysis. The large orthopaedic hand drapes with elasticated aperture are suited to providing full operating theatre sterility, suitable for major hand and wrist procedures including arthroplasty surgery. These drapes were switched to a smaller aperture drape that still afforded an appropriate level of sterility and field cover.

The sterile instrument sets were also a significant area highlighted during our analysis. A standard orthopaedic hand set containing 32 instruments was being used for CTD. These instrument trays were undergoing autoclave sterilisation at a significant cost following each use with many the instruments remaining unused. By rationalising the instrumentation required for performing minor hand procedures such as CTD into a smaller set of 10 instruments this significantly reduced sterilisation costs.

Further smaller savings were made by ensuring the use of appropriately sized syringes for anaesthetic administration. Skin marking pens were also not routinely used for incision planning.

A final meeting between the two hand surgeons and the operating theatre personnel was held once analysis and research was completed with the above proposed changes being put forward and agreed. All changes were instigated universally across the department at the same time.

Lessons and limitations

The primary limitation of this project is that it focuses solely on the cost minimisation of expendables used during CTD procedures. It is beyond the power of this study to establish the potential cost savings that could be afforded when such procedures are performed out of the operating theatre environment in clinic rooms, as is more common in the USA and Canada. This study also does not consider surgeon and operating theatre personnel costs, which is clearly a significant factor in costings. However, in our study, there was no change to the number of theatre personnel required to perform CTD procedures with the revised equipment.

When implementing the changes to practice there were a number of issues that arose. Due to the design of the study we instigated all of the proposed changes at the same time. We did find that this approach made things difficult for clinical staff initially. This was due largely to the fact that the clinical team had been performing CTD procedures in exactly the same way for a long period. The resulting errors involved wrong drapes and tourniquets being accidently opened and thus initially negating any savings to cost. In retrospect we would recommend that changes be instigated one at a time over a staggered time frame to allow clinical staff to adopt a single change before then moving on to introducing further changes to practice. By adopting this more organised approach these initial errors could then be minimised. We also initially found that we ran out rationalised instrument sets when we had more CTD procedures booked onto lists than we had sets. Although this problem was relatively easily solved once identified this could have been avoided altogether if clerical staff involved in booking patients onto lists had been informed regarding the maximum number of CTD procedures that could take place on a single theatre list during the transition period to new practice. More rationalised sets were rapidly put together and made available which resolved this issue.

The other limitations noted include the need for ongoing long-term follow-up to ensure infection rates postsurgery remain unchanged. Given the evidence available it was felt that the changes made were safe to instigate. Further research is planned in the form of patient satisfaction studies to insure there has been an appreciable improvement following the switch to using no tourniquet.