It All Adds Up

Cutting supply costs adds up to big savings

Editor’s note: “It All Adds Up,” by Kim Wood, RN, MBA, has generated some response from infection control practitioners questioning some of the article's content. We have reproduced an example following this on-line version of the article, and will address the concerns in the April/May 2005 issue of EndoNurse magazine. If you have concerns about any of the content of this article, please send your queries to jroark@vpico.com. For definitive answers to matters of infection control, contact the Association for Professionals in Infection Control and Epidemiology (APIC) at www.apic.org .

“A BILLION HERE, A BILLION THERE....pretty soon it begins to add up to real money.” That was the colorful assessment of a politician in Washington, D.C. a few years ago, when commenting on how the national budget is developed. But his jest contained the right idea: whether you’re talking about billions or pennies — they really do add up to meaningful amounts.

If your organization is seeking to reduce costs while maintaining quality care (and who isn’t?), your strategy may be focused on the more dramatic task of trimming the cost of bigticket items. That’s important, of course, because there are enormous savings to be obtained by clear thinking and positive negotiations. But the smaller, less dramatic savings opportunities should not be overlooked in the process. Sometimes it’s easier and faster to make the small changes that positively affect the bottom line — with no adverse effect on patient care. Decisions made in the endo lab each day can save “real money” on supplies.

As a national consultant on supply chain performance improvement, I advise client hospitals and systems on how to enhance their practice while reducing their costs. Individual reductions can seem minor, but the aggregate results can be astonishing. Here are a few examples gleaned from recent consulting engagements. The costs for supplies are from the Perspectives™ database of 1,600 Premier, Inc. member hospitals, a constantly updated information resource. Your own costs for these items may, of course, be higher — in which case, your savings will be greater.

Sterile water: Sterile water is indicated in some procedures, but often it’s used indiscriminately, for every purpose in the endo lab. Why use sterile water when the procedure isn’t even a clean one? The Society of Gastroenterology Nurses and Associates (SGNA) recommends that sterile water be used for irrigation, sterilizing the water bottle each day, and prior to each ERCP. A study1 using tap and sterile water concluded that tap water in non-sterile bottles is safe and cost-effective, while another study2 concluded that use of tap water is a more practical approach.

How much can you save by limiting your sterile water use to appropriate situations? Say your cost is $1 per liter bottle — and one bottle is used for every one or two cases. In a unit performing 5,000 cases per year, the great majority (as many as 90 percent) do not require use of sterile water. Limiting its use can mean a direct cost savings of $2,250 to $4,500 annually. And that represents only the purchase price — labor for delivery and stocking in a unit, as well as the precious space required for storage are also costs to be considered. All that’s required is an open mind and willingness to look at your choices and decisions in a new way, and you can be well on your way to savings on sterile water usage.

Patient slippers: Does every patient need to be supplied with slippers? Most would be happier (and probably more sure-footed, as well) wearing their own socks and shoes. Giving a patient a pair of slippers may have become an automatic response from your nurses, but it also has a cost. Each pair of slippers costs between $0.66 and $0.92. In our exemplar 5,000-case unit, that’s between $3,000 and $4,500 in annual unnecessary expense. Wouldn’t it feel good to save that much each year?

The suction canister: The suction canister is, perhaps, unsightly — but is that enough of a reason to change it after every procedure, when it may be only fractionally full? There is no possibility of backflow as suction is constant, so this is clearly an esthetic issue, not a clinical one. Some organizations have solved the problem very neatly — disguising it for patients by tossing a bouffant cap or paper towel over the suction canister. The cost of the canister is not inconsiderable, either. Suction canisters range in cost from $1.19 to $1.37, so the potential savings are very real.

Gowns: If it is not soiled or otherwise compromised, it’s not necessary to change your gown for each patient. Check out your physicians — you’re likely to see that they keep the same gown on all day, unless it is soiled. There is no good reason to change an unsoiled gown, and the annual savings can be very great if the practice is halted. An average price for a procedure gown ranges from $1.10 to $2.42. The savings will depend on how well the nursing staff observes this new way of thinking.

Sedative vials: Due to new pricing, multi-use vials of sedatives are not more cost-effective than individual dosage vials, although that once was the case. But that makes it even more important to use the appropriate sedative vial (e.g., 2mg, 5mg) that ensures the patient gets the amount specified by the physician without waste. These days, most GI facilities are moving toward Versed and Fentanyl instead of Versed and Demerol. Fentanyl is cheaper ($0.55) than Demerol ($0.70); in addition, Fentanyl has a quicker onset (2-5 minutes) and shorter duration (about one hour) than Demerol (under 5 minutes and 1-2 hours).

Suction tubing: Are you using sterile suction tubing when nonsterile tubing (sold in bulk lots) may be much more cost-effective? If you use six-foot sterile tubing exclusively, there is no cost savings opportunity in making a change, as the price is the same. You’re not paying extra for the sterile feature at that length. But if you typically use a longer length of suction tubing for each case, there is a cost-savings of $0.01 to $0.02 per foot for non-sterile tubing, which serves the purpose perfectly. Buying and using the non-sterile tubing does require some storage, but all the space you’ve saved by reducing use of sterile water will have freed up shelves for storing the tubing. The point is, in almost every case sterile tubing isn’t needed, so why pay extra for it?

IV extension tubing: Do you really need all the bells-and-whistles features of IV extension tubing? Or are you paying extra for features that are simply wasted? The ports that you use most often are closest to the patient in the basic IV set-up, and it’s most unlikely that you will need more than these for your patients. Your physicians (particularly anesthetists) may have a preference for the extension tubing, but it’s worth it to try to make this change. Worth how much per case? The average cost of IV extension tubing ranges from $1.10 to $2.04. Unless you’re regularly using the added ports, you are wasting that much for each and every case.

Flush container: Are you using a graduate (costing $0.18 each) as a flush container? Why? The same job can be performed by an emesis basin (costing $0.08) or even a 16-ounce cafeteria cup (costing $0.02 to $0.04). The measurement features of the graduate are not utilized, so why pay extra for them?

IV kit vs. swab/tape: The typical IV kit contains a number of items that are simply wasted — thrown away because they are not needed. So why automatically break out an IV kit (costing $0.90 to $1.23 each) when simply using an alcohol swab and tape (costing $0.15 for both) will yield the same result? Remember, an IV that you provide for endo procedures is rarely on the patient for more than an hour, so the long-term antibacterial elements (e.g., Tegaderm) that an IV kit includes are simply not needed.

EKG pads: Are you purchasing EKG pads in three-pad strips (costing $0.12 each pad) or in bulk bags of 50 pads (costing $0.09 each pad)? It’s really just as easy to use the bulk-packed pads, and there is a savings of nearly $0.10 per case when three pads are used.

Lubricating jelly: Individual foil packs of lubricating jelly cost about $0.04 each, and five packs or more can be used in a typical case costing $0.20 per case. In contrast, a 4.5-ounce tube of lubricating jelly costs $0.78, and it can be used for four or five cases, costing $0.16 per case.

Printer paper: High-gloss paper is expensive, costing $0.78 for each page. In comparison, plain paper costs about $0.06 per sheet for the patient’s chart, for a substantial saving with no reduction in quality. In addition, some units make a picture for the patient as well, doubling the printing cost to $1.56 per case. In a recent situation, clinicians were actually printing four pictures — one for the patient’s chart, and one for the physician, and one for the resident, and one for the patient. What about “one for the little boy who lives down the lane” — shouldn’t he have one, too? Reducing the number of pictures from four to one saved that organization $20,000 annually. We recommend eliminating all but the patient’s chart picture — the one that is probably the reason for using the high-gloss paper in the first place. Others are wasteful and unnecessary.

Suction can disposal: A good practice is to wear personal protective equipment, dump the contents of the suction canister into a hopper, and discard the canister in a regular trash bag (not a red biohazard bag). Suction cans are not hazardous waste and do not require that treatment. The average cost to dispose of a biohazard bag is $0.25 per pound, and a canister weighs approximately 10 pounds when full. Thus, the savings are approximately $2.50 per canister. In addition, it’s not necessary to use a solidifier, which can represent an additional cost savings of $1.32 to $3.02 per disposal. Dispense with these powder pellets to save substantially on every disposal.

Consolidate vendors: If your department is utilizing more than one or two vendors for forceps, snares and other endoscopic products, you’re probably spending more time and money than necessary. Taking into account physician preferences and nursing practice, it still should be possible to consolidate your vendors to a more manageable number. Your goal can be to standardize to reach a higher tier of products, but you’ll also be reducing the time and effort required to keep your unit properly supplied.

In working as a consultant with endoscopy units across the country, I have found these suggestions and others to resonate powerfully with department leaders who are seeking to do the best possible job while reducing costs. In truth, depending on the size of the unit and the volume of cases, these small changes and others have resulted in average annual savings of $25,000. In one remarkable instance, we documented annual savings of $320,00 for a five-hospital system. It seems incredible, but it’s true.

A penny here, a penny there...pretty soon it can add up to real money!

Kim Wood, RN, MBA, is a senior consultant in supply chain performance improvement with Premier, Inc. She can be contacted by email: kim_wood@premierinc.com.

Works cited:

1 “Endoscopy Water Source: Tap or Sterile Water?” Peterbaugh M, Barde C, Van Enk R. Gastroenterology Nursing, Vol 20 (6), November/December 1997, pp 203-06.

2 “Use of sterile compared with tap water in gastrointestinal endoscopic procedures,”

Wilcox C, Waites K, Brookings E. American Journal of Infection Control, October 1996:24, pp. 407-10.

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