Materials managers must focus on the efficacy of surgical drapes in maintaining a sterile field before they can even consider cost-saving measures. But that doesn't mean patients should be draped from head to toe for a carpal tunnel procedure in the name of infection protection. With an eye toward surgeon preference and tailoring the drape to the procedure, you can avoid waste in the purchasing and use of this line of barrier protection. Here's how.

Adequate access
Surgeon preference is a tired phrase, but clich?? or not, it drives a majority of the decisions made at surgical facilities. Materials managers likely feel that influence more than others do. A doc's preference for blades and gloves makes intuitive sense. They are, after all, the tools of his trade. But don't ignore the importance of ensuring he's working with his drape of choice.

Ask your surgeons for their drape preferences, make sure those drapes are stocked and ready for use, and match them to each surgeon's scheduled cases. As a young nurse, I learned that lesson the hard way after pulling the wrong drape for a procedure. Let's just say the drape I pulled flew across the room, and not because it suddenly sprouted wings or got caught in an eddy of circulating air.

While the surgeon's drape toss was way over the top, his point was well taken: Drapes must maintain the sterile field and offer protection for both the patient and staff, but they must also allow the surgeon adequate access to the surgical site. According to AORN guidelines, "Drapes should have limited memory and be flexible enough to conform loosely to the patient's contour, allow for placement and unhampered manipulation of surgical instruments and appropriately drape related equipment."

Incision drapes come with a pre-cut hole for placement around the surgical site. Check with your surgeons to confirm the size of the hole they prefer to work through. Ignoring their preferences could cause an avoidable domino effect. In the worst-case scenario, the unwanted drape would be pulled, the surgical site re-prepped to accommodate a larger exposed work area and a second drape placed. That's a waste of valuable OR minutes, of drapes and, ultimately, of money.

Large hospital systems can get away with stocking multiple-sized drapes to match physician preference at a moment's notice, but even those facilities are cutting back on bloated supply inventories. Outpatient facilities must always place a greater emphasis on staying lean and mean. A growing number of centers are using custom packs to ensure only needed supplies are pulled for each case. As a surgeon once told me, "Open only what I need, not what I ask for." Using custom packs that match your surgeons' preferences ensures they'll work with their drape of choice. But what if you don't use custom packs or use packs that don't contain drapes?

We stock custom packs for our carpal tunnel, knee and shoulder cases but also maintain a week's worth of loose drapes based on each surgeon's average weekly case count. Keeping a supply of loose drapes on hand — ours are 100 inches wide by 80 inches long — avoids wasting specialty drapes on cases that simply don't call for them, like the simple removal of biopsies or minor procedures performed on extremities.

The type of case is important to consider, but so is the patient positioning it requires. Here's what I mean. When pulling supplies, look at the type of procedure, but delve deeper. Where will the incision be made? Are multiple incisions planned? What patient positioning is required? You want to limit the exposure of the work area while providing the surgeon adequate access to the surgical site, but you also want to look for opportunities to save in draping. For example, let's say a procedure is scheduled for the removal and biopsy of two growths, on the outside and inside of the patient's arm. During this procedure, the arm will be turned 360 degrees so the surgeon can access both growths. In that case, you must wrap the patient's entire arm instead of toweling off the multiple sites and employing a smaller drape.

When multiple incision sites are planned for simple procedures, I've seen OR teams try to limit waste by using a single covering instead of opening multiple drapes. They prep and square off each incision site and place the drape's primary opening over the first incision site. After the surgeon finishes there, they feel for the squared-off area of the secondary incision and then strike through the drape to access the second surgical site.

That method saves on the opening and placement of a second drape, but is condemned by the Association for the Advancement of Medical Instrumentation — unless the drapes are intended for that use. AAMI says the cutting of drapes generates lint and goes against the principles of infection control. The group reminds us that the proper handling of barrier protection is critical to its cost-effectiveness and protection. Remember, drapes must first and foremost ensure a sterile field.

Safe and sound
Matching the drape to the procedure also calls for matching the drape's level of protection to the procedure type. AAMI outlines the level of protection offered by surgical drapes in its "Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities" report. AAMI says barrier protection should be strong enough to withstand stresses during typical use, in both wet and dry conditions. A drape's classification ranges from Level 1 to Level 4 protection. The lowest barrier classification, Level 1, is resistant to liquid impact penetration and suited for low-fluid procedures. Levels 2 and 3 resist liquid strikethroughs and increasing liquid pressures. Level 4 protection is said to resist all liquid penetration.

According to AAMI's "Selection and Use of Protective Apparel and Surgical Drapes in Health Care Facilities" technical information report (TIR11:2005), Level 1 barrier performance involves minimal exposure to fluid and therefore a minimal risk of exposure resulting from fluid spray or splash and soaking exposure from leaning on the drape. Simple biopsies, eye cases and ENT procedures fall under this level of recommended protection. Level 2 barrier performance is suited for procedures offering low risk to fluid exposure resulting from spray or splash and pressure applied on the drape. Endoscopic GI procedures and most minimally invasive surgeries call for this level of protection.

The third and fourth levels of barrier protection are suited for moderate and high risk of fluid exposure, respectively. Procedures that require this level of protection are likely suited for acute care hospitals; outpatient surgery facilities will provide adequate protection for staff by stocking Level 1 and Level 2 classifications of barrier protection.

Reusable drapes are available but drapes are used so often and at such a high volume that, in my opinion, the cost of utilities and staff hours involved in reprocessing the reusable drape materials would be cost-prohibitive in the long run. Also consider that the protection offered by reusable drapes will decrease after repeated use and reprocessing, meaning you'll have to track and document each time a drape is sterilized. That's a workload that can be easily avoided with the use of disposable drapes.

Before deciding on which drapes to use in your center, assess their quality and performance (see "Put Drape Manufacturers to the Test" on page 33). One of the best ways to avoid waste is to ensure that you're working with drapes that perform up to acceptable standards. Involve your staff in clinical trials. AAMI says you should ask staff to rate the drape's performance in barrier performance, strength, drapeability, staining, linting propensity and shrinkage, among other factors.

AORN says cost should not be the primary consideration when selecting drapes, but it concedes that the current surgical landscape demands you consider the health of your bottom line. The organization says the proper selection of drapes will contribute to the fiscal soundness of your facility because "a lesser-priced product that fails consistently is not cost-effective because additional volume will be required to replace the defective or poorly-performing item."