Switching to case carts took several months of planning and required a total makeover of our sterile storage area. So far, we've bought 32 case carts for our 8 operating rooms and 1 procedure room. The project cost about $300,000, but in the long run stocking carts the night before with everything needed for a case will save us time (once the cart is stocked, it only needs to be wheeled into the OR just before the case) and money (supplies take up less storage space and less of our time to pick). As you'll learn, it's been a lot of work, but it's definitely worth it. It's a better way to store supplies and stock your ORs.

The problem
Before the makeover, materials management staff stocked the basic products in the sterile storage area based on set par levels. Clinicians ordered all specialty supplies needed in the OR. Nurses received the schedule for the following day's cases and picked the supplies and instruments based on the surgeons' preference cards. The nurses gathered the supplies, placed them in totes and loaded mobile back tables and a few rarely available carts. Several cases for the same operating rooms were combined on the same table or cart.

Preference cards often didn't have enough information for support staff to locate products. Experienced nurses could set up fairly quickly, but it took newer nurses much longer. Stocking tables and filling totes often required more than 1 trip through the storage area. The whole process was very inefficient. Plus, the nurses didn't like ordering, managing and locating supplies. Every year they mentioned it on employee satisfaction surveys as one of their least favorite tasks because it took them away from caring for patients.

Making space
In order to switch over to the case cart system, we first had to create enough open space in the storage area to accommodate the carts. A design consultant created a new storage system of high-density shelving based on the flow of material, the carts and the location of the ORs. We consolidated supplies that were spread out across our unit and moved equipment that belonged to other departments off our floor.

Before, the main supply storage area for sterile instruments, medical supplies and equipment was arranged in 2 parallel rows of shelving that weren't wide enough to accommodate a cart or back table. This area wasn't labeled and had poor lighting, making it difficult for staff to locate supplies.

As part of the makeover, we replaced solid plastic shelving and hard plastic bins with steel wire baskets and shelves. This conversion alone increased the storage capacity in the sterile storage area by about 30%. Wire shelving may someday become a standard of care for infection control because it helps prevent dust accumulation, as the dust falls through the small gaps in the wire rather than piling up on the shelf and in plastic bins. In compliance with Joint Commission standards, the bottom shelves are at least 8 inches from the floor and the top shelves are at least 18 inches from the ceiling.

The wire racks are also an improvement because they keep supplies accessible and visible. This helps the materials management staff keep track of inventory. With the plastic bins, items could get lost or hidden more easily. When we were removing the bins, we found several expired and overstocked supplies behind them.

Logical setup
The sterile storage area is a large room with 2 corridors leading to each scrub sink area, bordered by doors into 4 ORs. With the new design, nurses can push the case carts down a wide aisle and pull the material needed for each case. It's not that different from shopping in a hardware store. Custom packs are stacked on collapsible track shelves. Long items such as urology catheters hang from hooks. Small fragile items such as blades, burrs, bits and needles are stored on metal wire shelves with dividers.

Supplies are stored in horseshoe-shaped sections based on clinical specialty. Items used in most procedures — gloves, hats, sutures and drapes — are stored at the end of the storage area where the person stocking the cart begins the process. The wire shelving came with dividers, which let us build bins for each item to fit the corresponding par level, which is key to avoiding overstocking.

The storage section for each specialty is located as close as possible to the OR where those cases are performed. For example, since ENT cases are typically performed in the smaller ORs at the east end of the sterile storage area, ENT supplies are stored on the east side of the room. Orthopedic supplies, meanwhile, are stored closest to the larger ORs on the west side.

Instruments are stored at the far end of the room, closest to the door leading to the clean side of central sterile, so that the sterile processing staff doesn't have to go very far to restock the shelves.

Custom packs, orthopedic supplies and other large items are stored on track shelves that take up less space than stationary shelves because they can be compacted together. Expensive implants such as bone-anchored cochlear and breast implants and supplies purchased for a specific patient, aren't kept in the sterile storage area. Instead, they're locked in a point-of-use system that creates an electronic record of the physician that requested the supplies, the patient they were bought for and the date of the case.

Sometimes we use a single cart for several small procedures scheduled in the same OR. At the end of the case, during room turnover, the nurse or tech needs only to push the cart with used instruments into the central sterile department. There the instruments are reprocessed and the cart is sterilized in a large sterilizer. Once sterile, the cart is returned to the storage area where it is reloaded for another case.

Give yourself enough time
Before taking off on a large conversion project, plan ahead and spread the work over a period of time outside of the regular working day. During the initial planning stages, there was discussion about completing the entire conversion in a single weekend. We decided on phasing in the conversion over 4 nights in order to allow for feedback and contingency time. Changing over in the evening worked very well because it let the ORs continue their normal operations during the day without overwhelming the system.

Also, make sure that you have a plan to redistribute the shelving, containers, tables and carts that you'll no longer use. We had a plan for the bulk shelving and plastic bins, but we had to redistribute to other departments or give away many items that no longer fit into our workflow. Anything that doesn't have a new home takes up valuable space.

Still much to do
Later this year, we plan to train and assign materials coordinators to pull items and stock the carts based on the surgeons' preference cards. This will save on labor expenses and give the nurses more time to care for patients, which should improve staff satisfaction. However, we must first update the preference cards for accuracy. We will also focus on bin locations, material numbers and labeling so that materials management staff can easily find items on the preference cards.

The materials management staff has taken on more tasks appropriate to their roles. They now do the majority of the supply ordering — including specialty patient-specific orders — and manage all inventory in the sterile storage area. The materials team has worked to set par levels and manage inventory to meet and exceed budget expectations.

While the physical makeover of the sterile storage area has been completed, we're still transitioning case cart stocking from the clinical staff to the materials management team. We're phasing this in by specialty and OR room location in order to ensure accuracy and staff satisfaction. We're optimistic that the switch will improve employee satisfaction, help us stay on budget and let the OR team provide excellent patient care.