By Richard P. Mills, MD, MPH, Chief Medical Editor, EyeNet
My recollections from my first ophthalmic practice have been diffused by the years, so excuse the poetic license. I believe the chief of the only hospital in town was a fellow named St. Peter, and the Sisters of Providence supervised all that happened there. In her freshly starched nurse’s habit, Sister Mary was assigned to my operating room (OR). When I emerged from a scary intracapsular cataract extraction (they were all scary, with the vitreous face pulsating menacingly in the pupil), Sister Mary inquired why I had needed two packages of 10-0 nylon suture to complete the case. “One dropped on the floor,” I ventured. “In the future, doctor, please be more careful. These sutures cost $15 per pack.” I was mortified, since my family knew me as frugal to a fault, and I was too recently a trainee to take umbrage at being challenged by a nurse.
After a short while, the hospital acquired professional hospital administrators, and the sisters were transitioned to pastoral care and out of patient care areas. Cost consciousness became a subject to which we paid lip service, but not brain service. There were no Sister Marys to serve as role models; we traded them for the Joint Commission on Accreditation of Hospitals (JCAH), later to become the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Fast-forward to the present. I don’t know if you’ve noticed the behavior change in your local hospital when the JCAHO surveyors come to town. It looks like a cheap remake of the original King Kong movie. Quaking in their boots, the hospital staff quietly practices reciting the Mission Statement, knowing where the fire axe is kept, and cleaning up trash bags from the hallways. You see, a hospital cannot afford to mess up a JCAHO accreditation; in fact, even a citation is a wound requiring two or three additional staff hires to heal. Twenty-five years of this kowtowing to JCAHO, and there are 100 extra staff people just to comply with the requirements. And then there are the rules from the State Board of Health, Occupational Health and Safety Agency, and other watchdogs to boot.
It’s against this backdrop that David G. Hunter, MD, PhD, raised an alarm on his listserv about a Boston Children’s Hospital rule that a new bottle of eyedrops be used in the OR for each patient—used once and then discarded. Other colleagues from elsewhere said the rule was being applied in their clinics, too. Manufacturers have no incentive to make tiny bottles just for the OR and clinic; the volume isn’t high enough to justify. The result: profligate waste. JCAHO is trying to eliminate flash sterilization in the OR. Instead, the delicate eye instruments are sent to central processing, where the staff handles orthopedic hammers and crowbars. Turnaround is slow enough that six full instrument sets are required instead of three, and instrument damage is endemic. Profligate waste, again. Preassembled case packs of drapes and towels usually contain far more than will ever be needed; the rest are discarded, or “recycled,” but still wasted. Profligately. My OR uses lavender marking pens in the preop area for surgeons to mark the operative side a safety procedure I strongly support but requires the pen to be discarded after one use. It’s only 10 cents, but it rankles me each time. It makes me miss Sister Mary, though I don’t miss the rap on the knuckles with her ruler.