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Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative

  • Allison Shaw
    Affiliations
    Center for Quality & Safety, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA
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  • Author Footnotes
    1 Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 5323 Harry Hines Blvd., Dallas, TX 75390, United States of America.
    Yvonne Y. Chan
    Footnotes
    1 Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 5323 Harry Hines Blvd., Dallas, TX 75390, United States of America.
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA
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  • Author Footnotes
    2 Department of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 101 Manning Drive, Chapel Hill, North Carolina 27514, United States of America.
    Hans C. Arora
    Footnotes
    2 Department of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 101 Manning Drive, Chapel Hill, North Carolina 27514, United States of America.
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA
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  • Jazmina B. Aguilar
    Affiliations
    Procedural Services, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA
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  • Jamie Schechter
    Affiliations
    Procedural Services, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA
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  • Edward M. Gong
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • David I. Chu
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Elizabeth B. Yerkes
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Derek J. Matoka
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Catherine M. Seager
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Diana K. Bowen
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Bruce W. Lindgren
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Dennis B. Liu
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Max Maizels
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Earl Y. Cheng
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Emilie K. Johnson
    Correspondence
    Correspondence to: MPH Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Urology, 225 East Chicago Avenue, Box 24, Chicago, IL 60611-2605, USA
    Affiliations
    Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA

    Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA
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  • Author Footnotes
    1 Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 5323 Harry Hines Blvd., Dallas, TX 75390, United States of America.
    2 Department of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 101 Manning Drive, Chapel Hill, North Carolina 27514, United States of America.

      Summary

      Introduction

      Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital.

      Material and methods

      Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new “Groin-Penis Tray” (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared.

      Results

      A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figure compares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5 min (p < 0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p = 0.34). The new GPT is 2.7 kg lighter than the prior tray. Median OR time remained stable (baseline: 91 min; post-implementation: 102 min, p = 0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later.

      Discussion

      This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives.

      Conclusions

      Summary Figure
      Graphical AbstractBaseline and Post-Implementation Measurements.

      Keywords

      Abbreviations:

      DMAIC (Define, Measure, Analyze, Improve, Control), GPT (Groin-Penis Tray), GU (Genitourinary), QI (Quality Improvement), OR (Operating Room), PRN (Pro Re Nata)
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      Linked Article

      • Quality improvement, pediatric urology, and you
        Journal of Pediatric UrologyVol. 18Issue 4
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          In this issue of the Journal of Pediatric Urology, two manuscripts (Fernandez et al.; Shaw et al.) highlight the power of and impact of an effectively designed quality improvement (QI) in improving operating room throughput and resource utilization [1,2]. Both of these efforts build off of rigorous QI methodology, providing an opportunity to reinforce these concepts and processes to the broader pediatric urologic community. Whether formally recognized or not, QI has been a bedrock of the surgeon experience for more than a century.
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