Institutional Medication Dispensing Categories: Medication Waste and Cost Savings Analysis
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1 Institutional Medication Dispensing Categories: Medication Waste and Cost Savings Analysis Paige Garber, PharmD PGY2 Critical Care Pharmacy Resident Katie McKinney, PharmD, MS, BCPS Director, Pharmacy Services UCHealth - University of Cincinnati Medical Center
2 Objectives Review departmental medication dispensing category protocol development, implementation, and ongoing quality improvement Analyze medication waste and cost savings trends before and after protocol implementation Discuss high cost medication dispensing categories and contribution to departmental medication waste and cost savings Detail pharmacy technician work responsibilities for continual protocol implementation
3 University of Cincinnati Medical Center West Chester Hospital UC Physicians Daniel Drake Center Lindner Center of Hope
4 Medication Waste Pharmaceutical waste = any pharmaceutical product that is: No longer used for its intended purpose Designated for discard Not returnable for credit Institutional intravenous (IV) medication wastage % of all intermittent IV orders Medication discontinuation Product expiration Am J Health Syst Pharm 2008 Jul 15;65(14): Am J Health Syst Pharm 2012 Nov 15;69: Health Care Manag Sci 2008 Mar;11(1):55-65.
5 Medication Distribution Processes Order verification Medication dispensing Centralized vs decentralized Medication delivery Pneumatic tube system Manual delivery Automated dispensing cabinet and medication cart refill Direct bedside nurse delivery Extra/missing dose requests Am J Health Syst Pharm 2009 May 15;66: Am J Health Syst Pharm 2012 Nov 15;69: Health Care Manag Sci 2008 Mar;11(1):55-65.
6 Waste Control Strategies Formulary management Manufacturer premixed products ADDaptor Use of optimal vial sizes and multi-dose vials Medication batch processes Establishment of standard concentrations, dosages, and base solutions for admixtures Am J Health Syst Pharm 2012 Nov 15;69:
7 Waste Control Strategies Efficient process for communicating IV medication changes (e.g. discontinuation) Audit and log IV medication wastes Missing/extra dose request management Secure medication delivery Am J Health Syst Pharm 2012 Nov 15;69:
8 Medication Waste Capture Manual vs proprietary system Product stock vs Electronic Medical Record (EMR) generated label Frequency: weekly, monthly, semi-annually Reimbursement opportunity Health Care Manag Sci 2008 Mar;11(1):55-65.
9 Protocol Development
10 Medication Dispensing Categories Pharmacy Process Improvement Committee (PPIC) 6 month development period monthly meetings Details appropriate management of select high cost, high frequency medications 1st dose verification, subsequent scheduled doses, extra/missing dose requests, and delivery methods
11 Medication Dispensing Categories Goals Reduce IV medication waste Reliably and safely deliver medications Guide decision making regarding first dose verification, subsequent scheduled doses, extra/missing dose requests, and delivery methods
12 Medication Dispensing Groups Categories are listed as Green, Yellow, Red, and Black Associated with the cost, frequency of distribution, and risk category of drug Pharmacy technician and pharmacist responsibilities Delivery methods Medication storage Medication examples
13 Dispensing Group: GREEN (High Frequency/Low Cost/Moderate Risk) Pharmacy Technician responsibilities: 1. First dose: Prepare initial dose of product 2. Subsequent scheduled dose: Prepare dose 3. Extra dose requests (missing dose, next bag, etc.): a. Reprint label and prepare for dispensing Pharmacist responsibilities: 1. Verify product and see technician responsibilities for extra dose dispensing Delivery method Can be tubed All medications NOT listed in the Yellow, Red or Black category UCMC Internal Data. Dispensing Category Protocol
14 Dispensing Group: YELLOW (Moderate Cost/High Frequency/Moderate Risk) Pharmacy Technician responsibilities: 1. First Dose: Prepare initial dose of product 2. Subsequent scheduled dose: prepare dose 3. Extra Dose requests (missing dose, next bag, etc.): a. Call nurse and ask for a second search of tube stations, patient bins, and bedside b. If workflow permits, send delivery technician directly to patient care area to help procure drug. c. If dose not found, reprint label and prepare for dispensing Pharmacist responsibilities: 1. Verify product and see technician responsibilities for extra dose dispensing Delivery method Can be tubed UCMC Internal Data. Dispensing Category Protocol
15 Dispensing Group: RED (High Cost/Low Frequency/Moderate Risk) Pharmacy Technician responsibilities: 1. Prepare initial dose of product 2. Notify pharmacist of labels generated in IV batch, extra doses, or missing dose requests Pharmacist responsibilities: 1. Subsequent scheduled dose (NOT extra dose request) a. Minimum of one hour prior to preparing product, confirm dose is still intended to be given at scheduled time (oral chemotherapy excluded) i. Check for retiming or discontinuation of order ii. Contact primary team or pharmacist in charge of the patient care area with any questions 2. Extra Dose requests (missing dose, next bag, etc.): Address directly with the nurse and/or contact pharmacist responsible for the patient-care area a. Send delivery technician directly to patient care area to help recover drug dispensed 3. If remaining drug supply seems insufficient notify buyer (via in person or ) and/or document on daily safety log Delivery method DO NOT TUBE Hand-deliver to RN Signature Required UCMC Internal Data. Dispensing Category Protocol
16 Dispensing Group: BLACK (High Cost/Low Frequency/High Risk) Pharmacy Technician responsibilities: 1. Notify pharmacist of labels generated in IV batch 2. Notify pharmacist of extra or missing dose requests Pharmacist responsibilities: 1. First Dose: Pharmacist in charge of the patient-care area will communicate duration, drug supply, and any other pertinent information with the dispensing pharmacist 2. Subsequent scheduled dose (NOT extra dose request): a. Minimum of one hour prior to preparing product, confirm dose is still intended to be given at scheduled time i. Check for retiming or discontinuation of order ii. Contact primary team or pharmacist in patient care area with any questions 3. Extra Dose requests (missing dose, next bag, etc.): Address directly with the nurse and/or contact pharmacist responsible for the patient-care area a. Send delivery technician directly to patient care area to help recover drug dispensed 4. If drug supply in central pharmacy seems insufficient notify buyer (via in person or ) and/or document on daily safety log Delivery method DO NOT TUBE Hand-deliver to RN Signature Required UCMC Internal Data. Dispensing Category Protocol
17 Protocol Implementation
18 Implementation Strategies Approval from Pharmacy Process Improvement Committee (PPIC) Staff education Informational Monthly staff meeting Handoff Protocol advertisement Pharmacy postings Electronic resource Product labeling
19 Example: Product Label
20 Cost Savings Analysis
21 Cost Savings Analysis 3-month before and after protocol implementation analysis March-May 2015 vs June-August 2015 Total medication milligram (mg) dispensed vs total mg wasted Associated waste cost Total IV medication dispenses and redispenses
22 IV Medication Dispensing Data Total # IV Medication Dispenses March April May June July August Before (March-May) After (June-August) Total IV Medication Dispenses 102,950 76,463 UCMC Internal Data. IV Dispensing
23 Hospital Census and Acuity Data Before (March-May) After (June-August) p-value Total Patient Days per month median (IQR) 13,370 (13,205-14,030) 14,219 (14,202-14,375) Case Mix Index mean (SD) (0.025) (0.019) UCMC Internal Data. Hospital Acuity
24 Medication Waste Analysis Before (March-May) After (June-August) % Relative Change Group Red Waste no (%) 22 (0.9%) 8 (1.2%) -63.4% Group Black Waste no (%) 5 (0.2%) 0 (0%) % Group Yellow Waste no (%) 389 (16.1%) 89 (13.6%) -77.1% Group Green Waste no (%) 2006 (82.8%) 556 (85.1%) -72.3% Total # Waste Products 2, % 73.0% decrease in total IV medication waste products UCMC Internal Data. IV Dispensing
25 Example: Daptomycin Before (March-May) After (June-August) Total # Product Dispenses Total # Redispenses no (%) 48 (13.8%) 56 (14.4%) Total mg Dispensed 195,800mg 255,650mg Total mg Wasted no (%) 3,100mg (1.6%) 500mg (0.2%) Mg wasted per dispense 8.9mg 1.3mg Waste Cost $2, $405.36
26 Waste Cost Analysis Before (March-May) After (June-August) % Relative Change Group Red Drugs $5, $2, % Group Black Drugs $3, $ % Group Yellow Drugs $42, $4, % Group Green Drugs $61, $11, % Total Waste Cost 112, , % Total Savings: $93,798.04
27 Top 20 Waste Contributing Medications 1. Vasopressin 2. Nicardipine 3. Nitroprusside 4. Cisatracurium 5. Nesiritide 6. Desmopressin 7. Fosphenytoin 8. Anti-thymocyte 9. Daptomycin 10. Micafungin 11. Norepinephrine 12. Levetiracetam 13. Voriconazole 14. Amphotericin B 15. Iron sucrose 16. Foscarnet 17. N-acetylcysteine 18. Amiodarone 19. Alteplase 20. Methylprednisolone
28 Top 20 Waste Contributing Medications: IV Dispensing Data Before (March-May) After (June-August) % Relative Change Group Red Dispenses % Group Black Dispenses % Group Yellow Dispenses 1,109 1, % Group Green Dispenses 1,639 1, % Total # Product Dispenses 3,476 4, % UCMC Internal Data. IV Dispensing
29 Top 20 Waste Contributing Medications Before (March-May) 79.6% decrease in IV medication wastes After (June-August) Total # IV Medication Dispenses 3,476 4,053 Total # Waste Products no (%) 729 (20.9%) 149 (3.7%) Total Savings: $83,626.49
30 Cost Analysis Limitations Accurate capture of wastes per specified time frame Price fluctuations Drug manufacturer shortages Formulary adjustments Cause speculation for dispensing trends Continuous infusions and re-dispense trends Product label reprint vs re-dispense Unknown/unidentified barcode scans
31 Ongoing Process Improvement Standardized waste audit and documentation Review assigned medication dispensing category for ongoing appropriateness PPIC monthly review Trends in waste capture Reassess standard concentration medication admixtures New hire education Annual review
32 Conclusions Implementation of medication dispensing categories decreased overall IV medication wastes Associated with substantial pharmaceutical savings Additional position (FTE) justification Ongoing process improvement initiatives and analysis of waste trends
33 Acknowledgements Jon Hicks, Pharm.D. Maria Guido, Pharm.D., BCPS Eric Mueller, Pharm.D., FCCM, FCCP Afshin Taleghani, Pharm.D. Jessica Winter, Pharm.D., BCPS
34 Institutional Medication Dispensing Categories: Medication Waste and Cost Savings Analysis Paige Garber, PharmD PGY2 Critical Care Pharmacy Resident Katie McKinney, PharmD, MS, BCPS Director, Pharmacy Services UCHealth - University of Cincinnati Medical Center
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