From the 2019 HVPAA National Conference
Dr. Jodi Sherman (Yale University), Ms. Janet Kozakiewicz (Yale New Haven Health), Ms. Stephanie Amport (Yale New Haven Hospital), Dr. Scott Sussman (Yale New Haven Health), Mr. Edward Silva (Yale New Haven Health), Mr. David Katz (Yale New Haven Health), Ms. Nigiar Polat (Yale New Haven Health), Mr. Abe Tharakan (Yale New Haven Health), Mr. Nilesh Amin (Yale), Mr. George Zdralea (Yale New Haven Health), Ms. Cherul Tynan (Yale New Haven Health), Ms. Josie Pinto (Yale New Haven Health), Ms. Janet Punzelt (Yale New Haven Hospital), Mr. Chu Hu (Yale), Ms. LeeAnn Miller (Yale New Haven Health)
Drug waste is a large problem in the perioperiatve setting, where 30-80% of the total volume is routinely discarded. At the same time, drug shortages are affecting our ability to deliver quality care. Drug vials are frequently too large for a single patient encounter; however policies prevent splitting them between patients when they are prepared in non-sterile environments such as the OR. By shifting drug preparation to the sterile pharmacy setting, vials can be split to prevent waste—a common strategy during times of shortages. Pharmacy prepared “pre-filled” syringes increase the shelf-life of these drugs. However, such repackaging must be informed by data management systems to ensure efficient manufacture. Clinician behaviors also drive drug waste. Providing cost and waste reports have been shown to reduce drug waste in the perioperative setting. None has yet been integrated into the data management systems for ongoing performance tracking.
To develop a relational database tool, linking electronic health records and pharmacy procurement systems, for automated tracking of OR drug waste volume and cost, to inform provider and pharmacy at Yale-New Haven Hospital by December, 2018.
1) To measure drug waste volume and costs, drug administration data was extracted from Epic anesthesia records and Optime nursing records. Total quantities of each drug, per case, were then subtracted from the smallest number of whole vials required to meet that need, to conservatively estimate waste volume. Next, the drug procurement database (McKesson) was linked. Total drug quantities administered (Epic) were subtracted from total quantities procured (McKesson), to estimate opened and unused (unrecorded) drug waste. Drug prices were also linked from the procurement database (McKesson), to estimate the cost of total drug waste. 2) To mitigate wasteful behaviors, a provider dashboard was created with relative and absolute waste performance reports, (Figure 1). 3) To inform a pre-filled syringe program to mitigate wasteful packing, an aliquot dashboard (Figure 2.) was created to assess size and frequency of dose administrations.
Drug waste for YNHH perioperative services is conservatively estimated at $1.2 million dollars.
Figure 1: Provider dashboard sample. Such information relays performance information in both absolute and relative terms, to inspire behavior change and also for personal accountability.
Figure 2: Aliquot dashboard sample. Such quantitative analysis can inform the most efficient manufacturing of pre-filled syringes by the pharmacy department.
Figure 3: Total medication summary sample. Demonstrates how integration of electronic health records and procurement records can be used to estimate drug waste. Such information can help to identify hotspots (drugs with high percentage of waste and/or high waste costs), as well as track facility performance.
We met our objective by creating a novel solution to OR medication utilization and waste quantification and reporting. Next steps include using the aliquot dashboard (Figure 2) to inform a pilot pharmacy pre-filled drug kit.
This tool can be extended to all clinical areas in all delivery networks, to inform and track clinician performance improvement, improve safety, and support pharmacy to optimize resource efficiency and reduce the impact the provision of healthcare services has on the environment. Thus, the Anesthesia Patient Safety Foundation has advocated for comprehensive pre-filled syringes since 2010, to reduce medication errors, however cost perceptions has been a perceived barrier to program implementation. Our work can demonstrate cost advantages to pre-filled syringes to aid program adoption.