As the cost of essential medications continues to rise, pharmacy and hospital leadership continue to explore cost containment strategies that will allow for patient care that is both comprehensive and efficient. The current supply of many vital drug products can be characterized as inconsistent at best; thus, concepts such as conservation and waste reduction are more important than ever.  

At the Women and Children’s Hospital, one of four hospitals comprising the Charleston Area Medical Center (CAMC) in West Virginia, we administer approximately 125 to 150 IV medications per day. Historically, a facility such as ours would routinely waste a significant quantity of IV medications throughout the daily IV batching process, particularly by preparing doses that are subsequently discontinued and not administered, and this was the case at our hospital. In an effort to address this issue, we made the decision to redesign the process of IV batch preparation and delivery to increase efficiency, save costs, and reduce what amounted to significant waste. 

Agents of Change
Two main drivers solidified the decision to alter our process of preparing IV batches. First, in late 2009, CAMC embarked on an institution-wide performance improvement plan, with the goals of improving patient care, limiting waste, and containing costs. With this mandate from administration in mind, pharmacy leadership subsequently attended the 2009 ASHP Midyear Conference, where several poster presentations detailed the benefits of switching from once-daily IV batch preparation to multiple daily batch fills. Having access to information on how other facilities accomplished this goal encouraged us to seek an analogous solution.

Evaluating Waste
Historically at CAMC, we performed on-site preparation of a single daily IV batch in order to consolidate the process,  a common approach used by many pharmacies for preparing and delivering IV medications. However, the once-per-day method requires that large quantities of IV doses be prepared and then delivered, thus increasing the chances that those doses will expire or no longer be needed. At our facility, this resulted in a significant amount of wasted product, and therefore wasted medication expenditures.

As a first step in revising our program, we ascertained the current amount of waste generated in our pharmacy by tallying the number of IV doses prepared, but not administered, over a four-month period from January through April of 2010. Our results indicated that we were wasting on average $5,909 worth of IV medications monthly—annualized to $70,908. This number was higher than expected, which further demonstrated the need for a more effective process. In order to plan correctly, we subsequently compared our batch fill operation with the processes of similar facilities, through benchmarking and a review of the available literature, and ultimately concluded that we could reduce a considerable amount of waste through more frequent IV preparation.



Instituting a Leaner Process 
The decision was made to  institute a multiple daily batch fill process that would require fewer doses to be prepared per batch with more frequent deliveries throughout the day, which we anticipated would greatly limit the incidence of expired doses. This complete redesign of the IV batch cart fill process involved several steps. When using the previous system, all doses for a single 24-hour period (from 3pm to 2:59pm the following day) were prepared around 7am daily and delivered at 2pm each afternoon. In order to ascertain optimal preparation and delivery times, we performed an analysis of our IV medication use to determine when most IV medication doses were ordered and administered. We then cross-referenced that information with staffing patterns, such as nursing shift changes and pharmacy shift times and peak workloads. 

The initial goal was to transition to compounding five daily IV batches, utilizing only existing pharmacy staff, without significantly impacting the timely completion of other pharmacy tasks. We also sought to minimize the impact of multiple medication delivery times on nursing staff. Our ultimate objective was to reduce IV waste by a minimum of 50% within the first four months of implementation of the new process. 

Eliminating Inefficiencies
At Women’s and Children’s Hospital, pharmacy leadership had been collecting observational data that suggested it would be possible to implement five daily IV batches without adding staff. For example, leadership witnessed instances of staff working slowly to make the work last throughout their shift. Purging inefficiencies could conceivably provide additional hours for staff to dedicate to compounding more IV batches.   

Gain Staff Buy-In
As is common with any process or workflow change, resistance to new methods occurs; thus, gaining buy-in from staff was critical to the project’s success. Because staff members were comfortable with the once-daily cart fill model, acceptance of the new method proved to be elusive at first. Initially, pharmacy did not involve or educate nursing on the new model; in retrospect, this should have occurred early in the process. When IV preparations were prepared and delivered only once each day, nurses were accustomed to picking up all of the IV medications required throughout their shift at one time. Upon moving to five-time-per-day delivery, nurses frequently received only one medication at a time, which occasionally resulted in confusion. Providing training to nursing and pharmacy technicians on the reasoning behind the change, the steps involved in the new workflow, and the expected benefits of the new process allowed nursing and pharmacy technician staff to quickly adapt to following new procedures. Once the staff had a full understanding of the new system and its importance to the department and organization, they embraced this change and worked to further decrease waste.

Workflow Adjustments
Our pharmacy is open 24 hours per day, seven days per week; thus, preparation of the largest individual batch is scheduled to be completed overnight, when the pharmacy is not as busy and more time can be dedicated to filling the largest batch. As a result, the oral medication cart fill processing time has been changed from 9pm daily to 10am daily to facilitate workflow processes and ensure all pharmacy tasks can be completed when required.  

Improved Outcomes
Creating a perfect system to completely eliminate waste is unrealistic, but maximizing waste reduction is a financial, ethical, and environmental obligation. Following four months’ implementation of five, smaller, daily IV batches, the average monthly waste cost burden fell from the baseline of $5,909 to approximately $1,246, totaling an annual savings of $55,956, a 70.6% reduction in wasteful medication spending. 

Following this success, we have continued to track our results in the months after the initial rollout. As of March 2012, twenty-four months of compiled data indicate more significant improvement than anticipated. We have realized current savings of more than $97,000 from baseline—an 82% improvement that far exceeds our initial goal of 50% less waste (see Figure 1). Perhaps the greatest measure of success is that we were able to implement the new process without requiring any additional labor resources. 

By increasing the efficiency of the preparation and administration of IV medications, less medication is wasted due to discontinuation of therapy and missing doses. Although some staff members may initially be resistant to changes in established procedures, overcoming this discomfort and effecting change can ultimately deliver substantial benefits in terms of both cost savings and improved patient care. 

Jennifer J. Gorrell is the Director of Pharmacy Services at Charleston Area Medical Center Women’s and Children’s Hospital and has been in this position since 2004, serving on a variety of multidisciplinary committees. She received her PharmD from the University of Kentucky School of Pharmacy in 1997 and completed both a pharmacy practice residency at the Medical College of Georgia and a pediatric specialty residency at the University of Kentucky Chandler Medical Center. Jennifer has worked in a variety of hospital settings, including in community hospitals, critical access hospitals, and tertiary teaching hospitals.