Banner Health (Phoenix, AZ) was selected as a finalist for ECRI Institute's 10th Health Devices Achievement Award for its implementation of a project comparing the cost-effectiveness of radio-frequency identification (RFID) technology with other alternatives for reducing the incidence of retained surgical sponges.
The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI Institute announced the winner and four other finalists for the 10th award in February 2016. For details about the other submissions that achieved recognition, see The Health Devices Achievement Award: Recognizing Exceptional Health Technology Management.
ECRI Institute congratulates the applicant, Terrence Loftus, MD, MBA, FACS, and the rest of the Banner Health team.
The Challenge
The challenge that Banner Health wished to tackle was twofold:
1. To reduce all serious reportable events (SREs) related to surgery, including the number of retained surgical items (RSIs), such as surgical sponges inadvertently left inside the patient during a procedure
2. To determine the conditions under which RFID sponge-detection technology would, and would not, be a cost-effective adjunct to the organization's program for reducing the number of RSIs
The Landscape
1. In the fall of 2010, Banner Health embarked on an ambitious journey to standardize its Safe Surgery Program throughout all the operating rooms and labor-and-delivery areas in its system, implementing the program in 22 hospitals of varying sizes and 8 ambulatory surgery centers by the summer of 2012.
2. The goal of the Safe Surgery Program is to reduce all SREs related to surgery. These include:
a) Wrong-site, wrong-patient, and wrong-procedure events. One process incorporated into the Safe Surgery Program consists of eight patient-focused steps to address these SREs.
b) RSIs, such as surgical sponges that are inadvertently left inside the patient during a procedure.
(1) A second process within the program includes 22 rules to help prevent retained sponges, sharps, and instruments.
(2) These rules are based on principles from the Association of periOperative Registered Nurses' (AORN) "Recommended Practices for Sponge, Sharp, and Instrument Counts," though the Banner team made the count process more robust by designing it to accommodate human information processing.
(Details about Banner Health's Safe Surgery Program were published in the January 2015 Journal of the American College of Surgeons article Implementing a Standardized Safe Surgery Program Reduces Serious Reportable Events.)
3. Of concern, however, was whether this program by itself would be sufficient to reduce the rate of RSIs.
a) The Joint Commission has recommended that healthcare systems research the use of assistive technologies to aid in detecting items that may still be in the patient (see the Joint Commission's October 2013 Sentinel Event Alert).
b) Accordingly, Banner Health's Supply Chain Services group was considering whether to invest in one such technology—an RFID sponge-detection system. These systems embed RFID tags into surgical sponges and use detection devices to account for sponges at the end of the operation.
c) To help with that decision, researchers at Banner Health sought to answer the following questions:
(1) Could a standardized Safe Surgery Program be effectively implemented and reduce the SRE rate?
(2) If a Safe Surgery Program is effectively implemented, could the results guide Supply Chain Services in its assessment of whether to purchase an RFID system?
The Process
Answering these questions involved designing methods to assess the effectiveness of the Safe Surgery Program and calculate the cost-effectiveness of an RFID system.
1. Assessing the effectiveness of the Safe Surgery Program. SRE data was collected and compared for each of the following:
a) A baseline period, which included more than 464,000 cases over a 32-month period, covering:
(1) The 12 months before the start of program implementation
(2) A 20-month period during which the program was implemented system-wide, staff were trained, and any required post-implementation remediation was conducted
b) A study period, which included more than 219,000 cases over a 16-month period
2. Calculating the cost-effectiveness of an RFID system. For their analysis, the researchers at Banner Health followed the model for calculating the cost-effectiveness of radio-frequency technology that was described in a 2014 article by Williams et al. This analysis was divided into four components:
a) Underlying assumptions. The Banner researchers incorporated the following information into their analysis:
(1) The annual number of cases performed in Banner Health's operating rooms and labor-and-delivery areas.
(2) The RSI rate for sponges, which is calculated by dividing the number of sponges retained by the total number of annual cases.
(a) The Williams article determined this rate to be 1:5,500 on average for hospitals.
(b) To assess various scenarios, the Banner researchers used the Williams figure, as well as the actual figures obtained during different stages of their study of the effectiveness of Banner Health's Safe Surgery Program.
(3) The percentage of the overall number of cases that would require an x-ray to determine whether a sponge had been retained. The researchers used the assumption that this would occur in 1% of the cases annually.
b) Costs of implementing the technology—This includes:
(1) The cost difference between the RFID sponges and standard sponges
(2) The cost of the RF wand covers used to cover the detection device (The manufacturer provides the other equipment needed to operate the system at no cost to the hospital.)
c) Costs saved or avoided as a result of implementing the technology
(1) Costs savings considered:
(a) The savings associated with not needing an x-ray for an estimated 1% of the total annual cases
(b) The savings for OR time, which was based on the average cost per minute multiplied by the estimated number of minutes needed to obtain an x-ray
(2) Costs avoided were:
(a) The average cost per case of a readmission and reoperation required to remove a retained sponge
(b) The average legal cost associated with such cases
d) Net gain or loss, which equals the costs saved or avoided minus the cost of implementing the program based on the underlying assumptions.
The Results
1. Assessing the effectiveness of the Safe Surgery Program:
a) The overall SRE rate dropped from 0.075/1,000 cases during the baseline period to 0.037/1,000 cases during the study period (p = 0.029)—an overall decrease of 52%.
b) The RSI rate for sponges decreased from 1:30,944 to 1:73,012. These rates formed the basis of the assumptions used in the RFID analysis.
2. Calculating the cost-effectiveness of an RFID system. The researchers assessed several scenarios:
a) Using published data—based on the assumptions from the Williams article:
(1) The RSI rate for sponges was assumed to be 1:5,500.
(2) The calculated net gain if an RFID system were to be used would be $5.86 million.
(3) In this scenario, purchasing the RFID technology would have made sense for the organization.
b) Using Banner Health's pre-intervention data—based on Banner Health's baseline data before the Safe Surgery Program had been fully implemented:
(1) The RSI rate for sponges was found to be 1:30,944.
(2) The net gain associated with use of an RFID system was calculated to be $444,268.
(3) In this scenario, purchasing the RFID technology would still have made sense prior to full implementation of the Safe Surgery Program.
c) Using Banner Health's post-intervention data—immediately after the implementation of the Safe Surgery Program:
(1) The RSI rate for sponges improved to 1:73,012.
(2) In this scenario, the calculated net loss associated with purchasing the RFID technology would have been $231,020.
d) Using more recent data:
(1) In 2014, the RSI rate for sponges had dropped even lower, to 1:158,730.
(2) With this new figure, the calculated net loss associated with purchasing the RFID technology would be $499,262.
3. Additional findings:
a) This analysis shows that as the RSI rate improves, the business case for RFID technology becomes less supported based on the assumptions of this model.
b) Additional benefits of the Safe Surgery Program are that it led to:
(1) A 70% reduction in wrong-site, wrong-patient, and wrong-procedure events
(2) Reductions in RSIs not related to surgical sponges—that is, items such as sharps and instruments that would not be detected by the RFID technology
Key Takeaways
Banner Health concluded that:
1. Effective implementation of a Safe Surgery Program can lessen the need for a technological solution to RSIs.
2. In fact, programs that can effectively reduce the SRE rate, including the RSI rate for sponges, may be a more cost-effective approach than using RFID technology to prevent retained surgical sponges.
3. Thus, awareness of an organization's SRE rate—and specifically its RSI rate for sponges—is essential before making a significant investment in RFID technology.