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Department of Anesthesia, Rhode Island Hospital, Providence, Rhode Island
Address correspondence and reprint requests to Richard G. Gillerman, MD, PhD, Department of Anesthesia, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903. Address e-mail to rgillerman @lifespan.org.
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Abstract |
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Implications: Unadministered drug amounts were measured for six study drugs over one fiscal year and found to be significant; the cost of unadministered drugs totaled $165,667. The reason most cited for waste was disposal of full, or partially full, syringes.
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Introduction |
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Drug expenditures can also be limited by decreasing waste of pharmaceuticals. Waste is defined as the appropriate or inappropriate disposal of unused or partially used ampoules, vials, or syringes of drugs. Decreasing waste is an attractive strategy because it does not limit specific drug selection by anesthesia providers. Data on drug disposal have been difficult to obtain, because only the amount and cost of pharmaceuticals ordered and distributed from the pharmacy could be calculated; to determine waste, it is necessary to know how much drug is actually administered to patients.
Anesthesia information management systems enable the calculation of drug amounts that patients receive, which permits calculation of drug waste. While one report comments on anesthesia drug waste (1), it was of limited value because the evaluation period was short (6 wk), and results did not include drugs that were drawn into syringes and later discarded.
We present information on drug waste at a large tertiary care hospital in two parts. The first reports on drug waste, and the second is a survey of anesthesia providers’ baseline knowledge, before interventions, of drug costs, waste, and their opinions about reasons drugs were wasted.
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Methods |
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Six drugs were chosen for tracking and analysis of drug waste: thiopental, succinylcholine, rocuronium, atracurium, midazolam, and propofol. Thiopental and succinylcholine were chosen because they are used in large volume. Atracurium, midazolam, propofol, and rocuronium were studied because they are expensive and were targeted previously for use reduction at our institution. Propofol was tracked also because it was thought that time restrictions on open vials would influence waste (5,6).
Sign out of drugs, without case type restriction, was required for atracurium, midazolam, and rocuronium at inpatient and ambulatory adult sites. Propofol sign out was required for use in inpatient adult operating rooms. All drugs were available in the children’s hospital. There were no limitations on opening vials, drawing up drugs, or full or partial vial disposal.
Drug administration data were collected by using a computerized anesthesia record keeper, ORDM v0.3.3c, (Draeger, Telford, PA). Study drugs were entered into the computerized anesthesia record that began recording on a patient’s entry into the OR. Data were stored in the application’s database (FoxPro, Redmund, WA) and archived for later analysis. Analysis of the database and report generation was accomplished by using Drug Utilization, v0.3.30 (Draeger). Each query examined all records for a selected period and totaled amounts administered for the selected drugs.
A constant supply of each drug was maintained at each operative site and restocked as needed throughout the month by the pharmacy. The amount of drug distributed to the department was then determined by analyzing hospital pharmacy spreadsheets monthly and annually. All study drug pharmacy acquisition costs were charged to one of two cost centers for the department of anesthesia. No amount of drug charged to anesthesia was used elsewhere except at anesthesia off-site locations mentioned above. External validation of amounts of drugs charged to anesthesia was determined by analyzing reports for rocuronium from the pharmacy accounts payable/materials management database, Enterprise Systems Inc. (ESI; San Francisco, CA). This drug was chosen because it was used nowhere else in the institution. All hospital rocuronium acquisitions from ESI were charged to the anesthesia department.
Total unadministered drug was calculated as the difference between the amount distributed by pharmacy and the amount administered for a defined interval. An efficiency index was calculated for each drug; the amount of each drug actually administered to patients was divided by the acquisition cost for the pharmacy for a given time period and expressed as a percent. The unadministered dollars for a selected drug were determined as the product of unadministered drug and the drug price as of December 1998. In some instances, prices changed during the study period. A cost index was calculated for each drug. This was the amount of dollars unadministered divided by the total dollar amount for all departmental drug expenditures for a selected period expressed as a percent.
A survey was administered to each certified registered nurse anesthetist (CRNA) and medical doctor (MD) in the department to assess knowledge about departmental drug costs, waste, and possible reasons for waste. No specific information on drug costs was given to providers before the survey beyond that which was routinely available to them from the pharmacy on request. Drug waste data were not shared with providers until completion of the survey, which was conducted after collection of drug waste data.
Provider survey responses were analyzed for differences based on the following variables: provider type (physician versus CRNA), employment status (full- versus part-time), years since training completed, and years employed at the study institution. Pearson 
2, one- and two-sample t, and the Mann-Whitney tests were used to analyze survey data.
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Results |
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Table 1 reports the number of milligrams charged to the department of anesthesia but not administered to patients and the annual drug efficiency index for each of the study drugs. These indices ranged from 29% to 61%. Efficiency exceeded 50% for only rocuronium and midazolam. More than half of every other drug studied went unadministered. The total cost of these unadministered drugs was $165,666.
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Questionnaire results, by variable, are shown in Table 3. The amount of dollars wasted was more accurately predicted by CRNAs than physicians, although statistical significance was not achieved as a result of wide variability in answers. CRNAs were significantly more likely than MDs to know the most expensive study drugs. There were no other significant differences in responses by the variables provider type, employee type (full- versus part-time), years since training, or years of employment at the study institution for the questions about the most wasted drugs based on volume or dollars. However, there was a trend that shorter-duration employees were more likely to know those drugs with the largest percentage of waste by volume.
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Discussion |
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The minimum estimated avoidable waste was $42,000. Two drugs had a cost-per-case to cost-per-vial ratio greater than one: propofol and succinylcholine. Succinylcholine dollar waste was minimal. Twenty percent of propofol waste was avoidable, about $17,000, based on the cost of propofol used per case in excess of the cost of the amount delivered to a patient per case, rounded up to a multiple of unit cost. Waste from multi-dose vials, atracurium and thiopental, was also classified as avoidable; atracurium was excluded because vials were charged directly to patients. Avoidable thiopental waste totaled $33,000, based on 100% use of a multidose vial; we estimated that 75% of this can be recaptured by provider education.
Potentially avoidable waste was identified further for atracurium, midazolam, and thiopental by examining vial size. An excessively large vial was identified for atracurium; this cause of inefficiency has been suggested previously (1). A switch was made from 10-mL to 5-mL bottles. The low midazolam efficiency index was attributed primarily to the preoperative holding unit, where providers administered only 1 or 2 mg of a 5-mg vial; a 50-mg multi-dose vial was substituted.
The amount of thiopental waste was much more than expected. Vial size, provider perceptions about cost, and use patterns for thiopental may explain the $32,000 of waste. The supply of the drug, 1-g bottles, was inefficient. There were no restrictions placed on the availability of thiopental. Anesthesia providers correctly perceived the drug as relatively inexpensive and may have felt little need to conserve it. Survey answers, which suggested that the most prevalent reasons for wasted drugs were the discarding of full and partially used syringes of drugs, most likely applied to thiopental; it is probable that drug was routinely drawn up and not used. These data prompted a switch to prefilled 300-mg syringes made from a 5-g stock solution.
The education of providers about use, waste, and cost is essential as perceptions of cost or total lost dollars for a given drug may be different from reality. Both MDs and CRNAs correctly identified thiopental and propofol as the two most wasted drugs by volume 70% and 73% of the time, respectively. Providers did a poor job of knowing the most expensive study drugs (Table 3), although CRNAs did better than MDs. This significant difference between responses may have been because CRNAs are more likely to administer drugs at our institution because they provide more direct patient care. However, any increased awareness did not continue with their responses to other questions. Less accurate for both provider types were predictions of the two drugs responsible for the most wasted dollars, propofol and thiopental. Only 10% of providers correctly predicted that thiopental was the second most wasted drug (based on dollars). These data may reflect a poor understanding of the interactions between volume of use, efficiency index, and cost as determinants of waste.
It is important to target only those drugs that contribute to a significant amount of lost dollars benchmarked against the total drug expenses for a department (Table 2) because such efforts may involve increased administrative time and additional direct personnel expenses. The drug cost index takes into account cost, volume of use, and the efficiency index to compare the total dollar amount wasted for a specific drug to the departmental cost of all drugs.
Sources of error for data used to calculate the efficiency index did exist, but we believe that overall results were not affected significantly. The following reasons would increase the efficiency indices slightly. Of the 25,481 anesthetics administered, 3.5% were not captured in the database. Both administered and unadministered drugs were not captured so efficiency indices were minimally affected. However, true dollars wasted and the real cost index would be increased somewhat by these uncaptured data. Propofol was the drug affected most because it was used extensively off site. Because efficiency indices were so low, it is unlikely that the conclusions of the study were affected significantly by these sources of error even, if the efficiency indices of the uncaptured drugs were slightly higher than those presented.
Another concern was the surrogate method used to determine the total number of vials for each of the study drugs used by the department for the month or year. Problematic was the fact that our pharmacy used an accounting method that had significant lag time from when a vial may have been used until its replacement was charged. The result was a significant monthly variability in the amount of pharmacy charges for a particular drug. For example, atracurium use varied from 80 to 120 vials per month. The standard deviations of mean monthly efficiency indices in Table 1 reflect the variability in drugs’ efficiency indices from month to month. However, when data were examined annually, we were able to ensure that no charges were carried over from the last month of the preceding fiscal year into the fiscal year studied; nor were charges from the last month of the fiscal year studied "lost" to the first month of the new fiscal year not studied. This was ensured by manual examination of pharmacy resupply sheets and using those dates versus spreadsheet charge dates for study calculations. Looking at an entire year of data made the accounting variations from month to month irrelevant. External validation of rocuronium charge data suggested further that annual waste data were accurate.
This study has shown that significant portions of anesthetic drugs studied were wasted during the study period, both avoidably and unavoidably. It is probable that other drugs not studied have similarly low efficiency indices. Extrapolation of the mean efficiency index for study drugs to all department pharmaceuticals suggests waste totaling more than $345,000 per year. A portion of avoidable waste and the associated expense, for those drugs with a high cost index, should be reducible.
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