If the experience of researchers at Duke University Medical Center is indicative of the nation as a whole, then infused medications are being wasted throughout the perioperative process.
This is the product of preparing and priming standard infusions regardless of patient and procedural characteristics. The good news is that such practices seem to be easily modified, a change that may ultimately save money and medicine.
“We have quite a few trainees in our busy cardiac practice,” said Tera Cushman, MD, an adult cardiothoracic anesthesiology fellow at the Durham, N.C., institution. “Being early in their training, the practice for a lot of them was to spike everything that came in the box. I believe they thought it gave the impression of being prepared and showing that they were ready for anything. Obviously, the disadvantage of this is that if you spike something, you can’t reuse it.”
Time for a Quality Improvement Program
Having observed all the medications that were going to waste, Dr. Cushman and her colleagues—a group that included seven of the 14 cardiac anesthesia fellows at the institution—undertook a quality improvement initiative aimed at reducing the amount of wasted medications.
The study began with a baseline study population of all first-start adult cardiac surgeries in September 2016. All pharmacy-dispensed infusions for these cases were marked, which allowed pharmacy to distinguish them and tally their return. A non-trainee representative visited each first-start cardiac case to record which infusions had been spiked. Then, the electronic anesthetic records were manually evaluated to determine which infusions were administered either intraoperatively or within one hour of the patient’s arrival to the ICU.
Wasted medications were defined as those infusions issued from the pharmacy that were primed but not administered to the patient in the perioperative period or not returned to the pharmacy in usable condition.
As Dr. Cushman reported at the 2017 annual meeting of the Society of Cardiovascular Anesthesiologists (abstract SCA210), analysis of 69 cases demonstrated that vasopressin and epinephrine were wasted with particular frequency.
Primed vasopressin was wasted in 22% of cases, while primed epinephrine was wasted in 39% of cases. In addition to an environmental effect, the waste also had a significant financial component. Indeed, the mean cost of wasted infusions was $110 per case.
Given these findings, the researchers set out to reduce waste and save money along the way, using three primary strategies. The initiative began by partnering with the pharmacy to reduce the cost of the standard medications traditionally distributed to each case. As Dr. Cushman discussed, these efforts included turning to norepinephrine or phenylephrine as alternatives for vasopressin, whose cost had risen substantially in recent years.
“Obviously it would be completely unacceptable to do anything that was less optimal for the patient,” she said in an interview with Anesthesiology News. “That was our first priority. That’s why we made sure we had buy-in from all our attendings with respect to whether this would be an acceptable change of practice.”
The second step in the initiative was to change the institution’s culture with respect to medication. As part of this undertaking, trainees and faculty were encouraged to engage in preoperative discussions regarding their potential choices during induction. These discussions were aimed at teaching trainees to only preprocedurally prime infusions that they would want ready for induction, and then spike additional medications on an as-needed basis during the case.
“If a resident has a conversation with their attending about why they picked certain agents, I think that would help enhance their education at an earlier stage,” Dr. Cushman said. “The idea is to create a shared mental model between team members about their goals and how they’re going to get there.” The initiative’s final strategy comprises a partnership with the pharmacy to improve the return of unused, unexpired medications.
A post-intervention survey revealed that similar proportions of epinephrine and vasopressin were primed and not used both before and after the initiative.
“However, both medicines were used much less frequently, meaning that they weren’t primed at induction time unless people had discussed it,” she explained. “So even though the proportion of medications that were primed but not used was the same, the per-case waste decreased by about 70%.”
Two-thirds of trainees who participated in the program had either positive or very positive feelings about the initiative. The remaining 33% were neutral. As Dr. Cushman explained, her institution is likely not alone in seeing significant amounts of medications—and dollars—flushed away.
“It wouldn’t surprise me to hear that other places are having similar challenges,” she said.
As Franklin Dexter, MD, PhD, noted, examining wastage makes sense for all organizations. “There are many ways to reduce perioperative costs,” said the professor of anesthesia at the University of Iowa Carver College of Medicine, in Iowa City. “An advantage in reducing wastage is that there are not potential unexpected consequences for patients or throughput. The work described in the poster seems an excellent example of such worthwhile efforts.”
Yet as Dr. Dexter went on to describe, waste reduction efforts must incorporate two important considerations to be truly effective. “First, as the authors here did, the analysis should be performed using control chart methods,” he said. “Consideration needs to assure that each period is large enough so that the end point is not correlated among periods.”
For example, if wastage is studied in cardiothoracic surgical procedures and different surgeons operate on different days of the week, the daily result would reveal different procedures performed, with different wastage. The period used in the control chart would then be in weeks or months, as case scheduling would create variability between days.
The second important consideration, according to Dr. Dexter, was how the different approaches to measuring reduction could change the effectiveness of the program. “If wastage were the focus, it is conceptually easier just to measure wastage,” he said. “However, often what is known are total anesthesia supply and drug costs, including waste. Total cost can differ markedly between surgical procedures. If changes in wastage were not monitored, but changes in total costs over time, then cost accounting per case can be unreliable statistically.”
Dr. Dexter suggested the American Society of Anesthesiologists’ Relative Value Guide units as a suitable denominator, as they control for differences between periods in the distribution of surgical procedures. Further information can be found in Anesthesiology (1998;88:1350-1356).