Our guests: Tyler Cramer, PharmD, BCPS Clinical Pharmacist at Boone Health and Kayla Sewell, PharmD, MHCI PGY2 at Lifepoint Health.
When it comes to controlled substance management in healthcare facilities, waste optimization plays a crucial role in both cost savings and diversion prevention. In this episode of Drug Diversion Insights, we dive deep into groundbreaking research on optimizing controlled substance waste with two innovative pharmacists.
Tyler Cramer, an inpatient clinical pharmacist at Boone Health in Missouri, shares insights from his AJHP-published research on maximizing opioid stewardship through fentanyl vial size optimization. Joining him is Kayla Sewell, a PGY2 Pharmacy Informatics Resident at Lifepoint, who recently presented her analysis of financial and workforce impacts of controlled substance waste at IHFDA.
Our guests explore:
– The catalysts behind their research initiatives
– Different approaches to studying waste optimization
– Key findings and their practical implications Implementation strategies lessons learned
– Integration of waste optimization into diversion prevention programs
Their research provides valuable insights for healthcare facilities looking to enhance both fiscal responsibility and diversion prevention through waste management strategies.
Whether you’re a pharmacy leader, compliance officer, or healthcare administrator, this discussion offers practical takeaways for optimizing your controlled substance management program.
Transcript
Terri
Welcome back, everyone, to Diversion Insights. My guests today are Tyler Kramer, he’s an inpatient clinical pharmacist at Boone Health in Missouri, and Kayla Sewell, a PGY2 pharmacy informatics resident at LifePoint. Both of these pharmacists have done some research on optimizing waste. Tyler has published in ajhp, and his title is Maximizing Opioid Stewardship Through Fentanyl Vial Size Optimization in an Independent Hospital. Kayla recently did a poster presentation at IHFDA titled Analysis of the Financial and Workforce Impact of Controlled Substance Drug Waste in a Community Hospital. For those of you that are at ihfda, and we did the panel with John Hurtig and Chris, and we discovered that titles for pharmacy research papers are quite long. We have to come up with some clever titles, but it’s very descriptive of what you did. Right. So we’re going to talk about that.
Terri
And let’s first start by getting to know our guests a little bit. And Tyler, tell us about your history with your career and where you are now and then what prompted you to do the research? Were you told to do it? Is it a passion of yours? Did something precipitate the idea for the research? So let’s start there.
Tyler
Yeah. Thanks, Terri, for having me on here. Listened to a couple of your podcasts and I think they’re great, addressing, you know, the entire story of what’s going on with the diversion and opioid crisis here in America. And a little bit of background about myself is I graduated from University of Missouri, Kansas City School of Pharmacy. I went to the Columbia campus. So for those of you unfamiliar with umkc, they do have satellite campuses, main campuses in Kansas City. There’s a satellite in Columbia and there’s a satellite in Springfield. So I went to the Columbia site. It was a little bit more. I have a rural background myself, so it felt a little bit more like home was closer to home. And I like kind of the smaller class sizes that were there.
Tyler
So starting out, I was an intern at Boone Health as a pharmacy intern and served there for four years. And after I graduated, I just jumped right on board as inpatient pharmacists and hasn’t haven’t looked back since then. Instead of doing a residency, I’m kind of learning as I go and picking up a lot of things. I do volunteer on ashps, one of their section advisory groups. It’s the Small and Rural Hospital Section Advisory Group. So every year we publish resources and put things out there for the small and rural community as Far as the opioid stewardship. And the study that I’ve done is Boone Health used to be an umbrella under Barnes Jewish, which is out of St. Louis. They’re kind of a very large health organization. And now they’re partnered with St. Luke’s as well, out of Kansas City.
Tyler
But around 2020, we separated from that umbrella and we became an independent hospital. And during that transition, we realized, hey, Barnes Jewish, since they were our parent, basically company, they were doing a lot of the things that we should have been doing for us. And one of those was they had their own opioid stewardship company that our opioid stewardship committee, and they set out guidelines for our hospital. When went independent, we no longer had that. And our pharmacy director was like, hey, does somebody want to try to tackle this? I wanted to get more leadership experience. So I took the ASHP Opioid Stewardship Certificate Training course. That gave me a little bit of experience on what opioid stewardship means, what kind of metrics we need to look for, and how to implement that into a health system.
Tyler
So then we put together over the course of a year, our opioid stewardship committee, we looked at what kind of metrics we can start measuring, which ones basically were going to be the low hanging fruit, which ones we could tackle easily. One of our Fresenius Kavi drug reps, he was actually coming around and talking about their new simplest syringes and the studies they had out showing reduced waste, reduced wasting events. And so that kind of really inspired it. And I was like, hey, I think we can implement that year to our hospital size. Because the hospital they looked at in their study was about a 300 bed hospital. And that’s what we are here at Boone. So that’s kind of what prompted me to pursue my study and also a little bit of background.
Terri
Great, Perfect. Okay, Kayla, how about you?
Kayla
All right, well, I wanted to thank you as well for having me today. Really excited to be here. My pharmacy journey started out a long time ago. Back in 2012, I was a technician. So from 2012 up in time, up until the time I went to pharmacy
school, I started in 2019, I was a pharmacy tech. And then when I started in school, I transitioned to a pharmacy. So I had a lot of experience operationally wise from both community pharmacy in the outpatient world and then also in the inpatient world, especially compounding a lot as well at a very large thousand bed hospital here in Nashville, Tennessee. So I had the opportunity for that insight that brought me to pharmacy school. I graduated in 2023 from Wilcom University here in Nashville, Tennessee. Also was really attracted to it because it is smaller.
Kayla
We do have University of Tennessee in Nashville too much larger. But I did find that I wanted to stay in Nashville for the great opportunities in healthcare and just experiences and relationships that the university was able to offer to me as a student. I also did go on to complete a dual degree there. While I was there for my PharmD, I did a master’s informatics. My interest in harmonics grew kind of into my P1 year there and so I decided to pursue that degree. And then afterwards I went on and got accepted into a or matched into a residency through Life Point Health. It is a combined PGI1 and PGY2 residency program. So I did start in 2023 right after I graduated I did complete my first year residency.
Kayla
It was in a very small rural community hospital there, kind of the flagship hospital for them. But LifePoint Health as a whole, it is kind of a family hospital. LifePoint, they do own lots of smaller community hospitals, more so out in the rural areas in the country as well, about 60, 63, 64 acute hospitals. And they do own a lot more behavioral health and inpatient rehabilitation centers as well. So really great experience so far. I have been able to see a lot of different flavors of multiple EHRs, different technology, a lot of just different practices as well. So it’s been great thus far. But part of kind of why I was interested in my research was that it was my PGI1 research project. And so my very beginning of last year, my residency had a lot of options presented to me.
Kayla
So normally your program will kind of have all these list of ideas of things that they kind of want to see, they want to kind of study and they’ll kind of present you a lot of different options. And so my program was fun. They presented it to me in a shark tank faction and so they had all the kind of project mentors there and kind of presented the project to me.
Kayla
And so I actually ended up picking the one I did just because I felt like it would make a lot of like meaningful impact for the particular hospital itself and just the ways that it can be incorporated like over the entire lifelong family hospitals as well, kind of standardizing that and bringing that any of those results come up, we can, you know, we can actually plan to incorporate those in our hospitals as well. But again, drug diversion, it was. It was one of my interests from the get go. So I was kind of naturally drawn to that.
Terri
Great, great. Well, and I love to see technicians that go on to become pharmacists because you know, it’s a. You start at the beginning and you really have that full understanding of what that all involves. And I think it also helps when you get on the management side, too, because you’ve been there, you know, and so I think that’s great. So good. Okay, so interesting history for both of you. Let’s talk about the studies then. So we’ll start with Tyler. Tell us about your study. What was your inclusion criteria? You know, what was it based around?
Tyler
Yeah. So, like I said, a big part of our study was first identifying that we didn’t have an opioid stewardship committee. And we kind of needed leadership in order to start to implement all these practices that we’ve been implementing over the past four years. So we first started out by putting together a multidisciplinary team that can make these decisions and make these changes throughout the hospital. And so, like I mentioned, Fresenius Kavi, I think one of the studies that they presented was the implementation of simplest fentanyl citrate injection, the 50 mics per 1 mil.
Terri
So fentanyl implementing the simplest.
Tyler
Yeah. So that. That study was kind of, like I said, presented to us from the Fresenius copy drug reps that we had here at Boone Health. And they kind of basically were trying to show us these new syringes that we could use. So we started out, we looked at all of our Pyxis data, what our waste data was looking at. We originally had the 100 mic per 2 mil syringes out, and we’re like, hey, all of our pain doses are 25 to 50 mics kind of on the bigger end. And sometimes we’re using 12 and a half mics. So it doesn’t make sense to have 100 mics of fentanyl out there whenever we’re wasting half the. Half the
dose every time.
Tyler
So that was the starting point, is we saw that the inpatient side or the inpatient units, those are going to be the easiest ones to change because a lot of them don’t have a lot of pushback. It’s nurse driven. So we had a lot of nurse buy in and they were comfortable with making that change. And then also the ER we identified, you know, they were wasting quite a bit almost every time they were using fentanyl. So it was going to be a big workflow change for them, and it was going to save them a lot of nursing time. So they were Also pretty adamant about making that change as well. The other units like or anesthesia cath lab, those people are a little bit more set in their ways.
Tyler
And it’s usually providers, CRNAs, people who may or may not have a little bit more pushback and that’s kind of how they practice. So we didn’t want to address them at first. We wanted to get a lot of the data from the nursing side and the nursing units. That way we could present that to them and say, hey, look, this is what we’re doing throughout the entire rest of the hospital. And this is, you know, we’re changing 60 to 70% of our wasting metrics. And when we had those data points, that really opened the eyes of all the other parts of the hospital and they’re like, oh, wow, yeah, we are wasting a lot. This can really help our nursing labor, our CRNA laborers in the or. We’re not having to grab a second clinician and say, hey, I need to waste this.
Tyler
Because our hospital policy, and probably most hospital policies are utilizing two individuals to witness waste. That way there’s a lower chance for diversion. So that takes a lot of labor. It takes a lot of time. I know, looking at a bunch of other studies that I had cited in mind that those workflow our time to waste studies. Basically it’s like $2.40 is the average waste every time we have to perform a waste. And fentanyl was our biggest contributor to that. So that’s kind of what we looked at and what we zoned in on.
Terri
Okay, so fentanyl was the only drug that you picked, right?
Tyler
Kind of for the study, yes. Fennel hydromorphone was a lot easier. It was, we use that basically for our post op ortho patients. And a couple times we’d use it in the er, but we didn’t use it nearly as much as we used fentanyl. And with the hydromorphone we already had the because of back orders and supply chain issues. I think in 2019, we had the 2 milligram per mil basically in all the cabinets. Then those went on back order. So we ended up getting the 1mg syringes and then we got the half a milligram syringes. So those just occurred because of supply chain issues. And we had already implemented that the fentanyl was the headache one because they use it a lot in the PACU setting. They use it for sedation, they use it for all kinds of other procedures.
Tyler
And so changing all of our order sets, changing our Procedure, habits, changing what we’re pulling. That took a lot more education. So the fennel was the one we included in the study because it was a lot more work. It was bigger numbers that were changing. Hydromorphone and also morphine. Those we all changed as well, right?
Terri
Yeah. Okay, that makes sense. And it’s very different on a nursing unit versus a procedural. Right? Because nursing unit, they’re only supposed to use the one dose and then throw the rest away. Procedural area, they can do that incremental dosing. And then they’re like, oh, we don’t want to go to the machine again. So you kind of gotta, you know, look at that whole thing, right? It’s like, well, we like it when we have leftover because then we have to go back. Yeah, exactly. Okay, Kayla, tell us about yours. What. What did you include in your study?
Kayla
Yeah, so for my study, I actually included three different units in our hospital. And I purposely excluded the operative areas. The reason being so was because in the small hospital that I did the research in is in our normal inpatient unit that I did the ed. I did a. Let’s see here. It was the ed, the ccu, the critical care unit, and then kind of like a cardio floor as well. The reason I did that was because we have very standardized practices in the practice of nursing is. And also pulling from our ADC cabinets is very standardized. And the way we waste, our process is very standardized too. So we do have a drug diversion prevention surveillance system that we use that also helps montrez that.
Kayla
But in our OR and perioperative areas, they don’t have a very standardized process for, you know, they have a different type of program or technology they use to document their administrations. And so it was just. It wasn’t very easily done in that sense. And they have their own culture in different. So I really wanted to focus in on the areas that I knew that we had the most wasted from, and those are our inpatient units. But what I had done is I had. First I wanted to pull reports based on our wastage, and I did that by looking at our ADC reporting. So I went through and found the top three drugs that we did the most waste on. And that was fentanyl. That was the fentanyl 100 per 2mL and then the hydromorphone, 1 per ML, and then lorazepam 2 per ML.
Kayla
So those are the three medications that IV push that we had the greatest amount of waste in. And also I picked the areas I Picked in was also the areas that had the most wasted, but also because they were the most interesting, because they have similar standard of practice. But the ED is the wild west, we all know that. And then the CCU is a little bit more controlled, but we still have a lot of critical care and emergency situations there. And then the other unit, that’s just your typical internal medicine, you know, cardio unit that you have, so you kind of see a little bit of everything in there. And as far as the usage is wise as well. But kind of the reason prompted this again, John Turkic study was a great model for that.
Kayla
I did try to model this very similarly. So I did do a lot of observing to these units and it was great because I got to see a lot of just between the variation of layouts in the hospital where our ADC cabinets were located, the availability of staff to witness, and then also the proximity of the cabinet to patient care areas and then also the proximity of where we actually are wasted them. So our little wasting bins that we had as well. So all these factors played into a huge part in that. And I did find that obviously in the ed we had a lot more fentanyl wastage, whereas in some of our other units we had more hydromorphine wastage as well.
Kayla
But really from the study, looking at how I could try to decrease that in any way, and I immediately found some areas to improve upon. And those kind of came up to be, you know, what are we using, what package size, what strength are we using in these areas? And I immediately identified trends and what was the most common dosage that was being used in these areas and the most common wasted. And so immediately identified that and found all these opportunities. So again, with nursing dollars and then also with the amount of money spent on these medications and the amount that’s wasted by that, think about how financially that could save a lot for the hospital, but also for the entire corporation.
Kayla
But lastly, not just that the actual amount of physical drugs that we’re wasting every day, every hour, every week, every month, we do have all of our ADCs located in a very secure area. But the way that we do kind of, I guess you would say waste them, we also have those little waste kinders next to, we also have cameras as well. So we’re, you know, utilizing a lot of those waste containers. The more medications we have from our drugs conversion standpoint and so just trying to find ways to decrease that overall. So.
Terri
Right, yeah, well, and then the nursing satisfaction too, right. I years ago, when I was at an independent hospital. And finally hydromorphone, 0.5 milligrams came out, and we put them in the ED and they had to get used to the whole new syringes, but to them it was worth it. And all of a sudden, I was their best friend. Right before that, I was just kind of annoyance. It’s like, you know, we’re going to go profile, we’re going to do that, and they’re like, oh, you know. But when the 0.5s came out, it was like I went and manufactured it myself. I mean, all of a sudden they loved me because it is so much work for them to, you know. And, you know, they’re going to waste it every single time.
Terri
There’s going to be waste, or you hope there is anyway, because you don’t want to go in one milligram necessarily. Right. Okay. So you did more drugs, but same principle. So tell us, Tyler, what were your findings in general? Did you. You know. Because there’s the cost. Well, not. Well, you tell us. This is. Are the. Is the fentanyl 50 more expensive than the 100 microgram? There’s the other costs involved, but sometimes that’s why pharmacies are not willing to purchase the smaller one. Right. Because it’s more expensive and they don’t want it to go onto their budget. Understandably so. But that’s what you find. So what did you see in terms of cost of the drug versus waste and all of those costs?
Tyler
So I think what I. What I heard was you were mentioning the. The costs associated with the findings and what the, like, the
numbers look like.
Terri
Yeah.
Tyler
From our study. Is that correct?
Terri
Yep.
Tyler
Okay.
Terri
Yeah.
Tyler
What? So, yeah, so from the study, like were mentioning, the ER had the biggest impact. And like you said, when we demonstrated this with those 50 mike fennel syringes. Yeah. We suddenly became their best friend because they went from, you know, rough numbers, not what was quoted in the study, but we’re doing like 300 waste events in the ER just for fentanyl alone. And when we switched these, all of a sudden we drop down to 15. So we had, like, we’ve maintained that number. Usually if I have more than 20 waste events in a month that I’m observing, then something’s probably wrong or somebody needs training or we’ve had a busy ER month.
Terri
Okay. So that was a big decrease in the number of wastes that you did. Okay. So you went down to much less waste. That was a huge difference. What you find from a cost perspective, obviously, you were saving money there.
Tyler
Yeah. So from a cost perspective, so this was kind of more. This was harder to pitch to. Like, C suite is, you know, technically, the 1 mil vials and 1 mil syringes, they cost more than the 2 miles vials that were available. So from a drug cost standpoint, these are more expensive. So then, you know, using these, the studies that have come out, like, from John Hertzig and the cited in my study about how much time it takes to waste the supplies that are going into it, like the syringes, the needles, all that kind of stuff, it’s $2.40 was the rough number that came out of that study. So, like, looking into that, I think it’s a dollar difference from our AWP costs between syringe and bile, going from the 100s to the 50s.
Tyler
So then using that arbitrary labor amount, then we’re netting, you know, $1.40 per waste event. So since those are, you know, fake numbers, you know, we’re saving money. It’s not actual spend money or drug spend money. That’s always hard to pitch to C suite because they actually want hard numbers. Like, hey, this is really what this is costing us. But the bigger thing was showing them the micrograms of fentanyl that went from is since the study, rough numbers going from, like, September 2021, were wasting, like, almost 80,000 micrograms of fentanyl a month, which was an enormous amount. And during COVID were using a lot more fentanyl, definitely for, like, sedation purposes and pain purposes. But since then, we’ve used less. So that kind of helped influence that number to come down.
Tyler
But now, like, even through the whole health system, that 80,000, now we have roughly 15 to 20,000 mics is our normal monthly waste. So showing the C suite, that number, they’re like, oh, wow. So there’s a lot more fentanyl that’s not going out. It’s possibly being pocketed. Not accusing anybody of diversion, but if we’re eliminating the fact that they have to waste it, then most likely we’re eliminating those diversion opportunities. So that’s really. Those numbers help drive it. And like you had mentioned at the beginning, we have continued to implement the study into more areas, and that’s how we keep driving our numbers down from the numbers that I’d actually published.
Terri
Okay. All right. Wow. That’s a big difference. Kayla, what’d you find?
Kayla
All right, so from our three units that I did look and study in our hospital, we actually, you know, My first impression was that there’s going to be a lot of fentanyl wasted. You know, we utilize the 100 micrograms per 2 milliliters. And at first that’s exactly what it looked like. But once started digging deeper, I realized that our hydromorphone was way larger in terms of waste and not just the actual amount of wasted product of milligrams of the Jordan being wasted, but also than just the cost. So at that time, fentanyl was very cheap to us from our wholesale distributor. Hydromorphone was the most expensive. It was more expensive than Ariazepam as well. And so really started to hone in on that one just because it was the big one.
Kayla
So in our ED, we found that because we have that 1 milligram per milliliter, and again, the most average dose is going to be that 0.5 milligram. And so just looking at that, you know, I did find that because of that extra, about half amount of our hydromorphone was being wasted, it has the highest cost of pharmaceutical waste in terms of money per se. And so looking at that, it was also. It takes the longest to waste as well, because I did find just across different units, some will hold on to it, some will go administer it and hold on to it, come back, and I may get distracted in the patient’s room or distracted along the way. But.
Kayla
And then it was a lot easier for saying other units when you had a buddy that was sitting there right next to you and you could immediately waste it upon, you know, dispensing it from the cabinet. So it was much easier, but in different places, it was hard to find witnesses. So I found that because of that variation in our units and our patient care areas, that one did take the longest, which cost more kind of in the financial standpoint of nursing dollars, to waste the longest time to waste there. So. But that being said, lorazepam was also another major player with that. As we all know, lorazepam doesn’t come in a lot of options there for our sizing and standardization of dosing. So we did have the 2 milligram vial with that.
Kayla
And at the time that this was happening, that was when we did have lorazepam shortage as well. So it was kind of hard to get in lorazepam itself. But again, that one, it comes in a vial, whereas a hydromorphone and arfentanol came in syringes the time. So that did pose a little bit higher time to waste or workforce time Waste as well, because you’re taking an extra step of drawing up that waste, another syringe, and then also wasting that as well. So with that, I found that also to be the kind of highest in the time it takes the workforce time waste as well.
Kayla
So with this project, honestly, fentanyl kind of was on the lower end, and I mainly focused on in honor, hydromorphone and what we could do to kind of mostly optimize what we’re ordering, where we’re storing it, you know, that type of thing, so we can decrease all this waste we’re seeing. And so basically what I had kind of found was, is that we had about close to $2,000 in savings if were to switch the hydromorphone over to our 0.5, 0.5 millimeter, 2,000 per month. Yes.
Terri
Okay.
Kayla
So that was just. And that was just for my study. That was extracted for my study data points as well. And the time it took for that as well. And then also for the Razapam, again, that being also taking longer to waste as well, that was around if I were. If were to change that for my vial. Our wholesaler did offer a syringe version of Arazepam at the time, which in theory would make it a lot shorter for the nurse to waste, per se. And so instead of, you know, drawing up another, getting the syringe out, extra steps, you’re eliminating extra supplies, you’re eliminating extra time it takes as well. So just kind of eliminating, you know, based on process supplies.
Kayla
And then the time it actually takes to do that was roughly around $3,000 in savings for that, just for the workforce time aspect of that, not just, again, the time it takes to waste that medication there. So really honing in on that. But the biggest thing I did is I really wanted to see how to extrapolate this across a year. So that’s what I kind of did with my results. As I extrapolated my one study from my small hospital extrapolate across the year, and basically found that those savings, if you extrapolate Those to our 63, 64, 65 acute hospital there, you could have. You could have a really great impact on savings there. And so if I extrapolated that and changing just those two things there from the rise of the hydromorphone, there was approximately 127, $120,000 saved.
Kayla
And just switching over to that hydromorphone, about 5 milligrams, and then $273,000 from switching over to lorazepam and so that’s huge savings. And for us, the amount to switch from those packages into those different dosage forms, we found that it was very little and very minute, so it was sent to dollars more. And because these are high utilization products, it would result in much more greater savings in other areas such as, you know, our waste bins. We’re putting the products in the time of taking the nurses, better nurse practices as well, higher satisfaction for the nurses as well. And then also just removing that drug from being out there. And so in that.
Kayla
And just, and just from my experience of, you know, actually looking at, and you know, reading about different drug diversions, you know, stories that come up in the news, decreasing and just eliminating that amount that can be found is huge. And in this case, not only are reducing that like amount from switching products, but we’re, you know, we’re decreasing the amount of money spent on that waste and the product itself over time. So, yeah, it was a really great finding.
Terri
Yeah. Wouldn’t it be nice if you could get a percentage of your savings, your research savings in your salary bonus. PGY2 bonus. Wow. Yeah, that’s big numbers. And especially when you have many facilities that you can roll that out to. Let me clarify on the Ativan, the Lariazepam, because I was like, ooh, is there a smaller one available? So there’s not a 1mg available, but there is a syringe available now.
Kayla
Yeah, at the time when I did, when I did my findings on this, or wholesaler had the option to purchase a syringe form with 2 milligrams. So, and this was I. And so during the time that I collected this data, there was a shortage, so were unable to get a syringe in that. But when I went back and I looked at what was available at the time, you know, this was a month or two later, they were, this is after the shortage they had at the comeback order, they actually had a syringe to be able to purchase.
Tyler
So.
Kayla
Yeah, and I mean that’s a win either way. You know, you’re leaving a little extra time out to waste, you know, extra supplies and so forth.
Terri
Yeah, well. And then it’s just, I think, yeah.
Tyler
If you’re referring to, I was going to say if you’re referring to the, maybe the ones that we could purchase as well. Correct me if I’m wrong, but is it just the carpe jack like syringes that are available? I think that’s all we can purchase is the carp eject and then the vial. That’s why we’ve had the reservations against the syringes, because they’re. The nurses always lose that device. And then they’re getting a syringe and drawn from the top of the carpet. And were looking to implement that here, and we’re like, oh, yeah, we can do that. And then we saw what it was. Or like, oh, we don’t want that. We try.
Terri
Right?
Tyler
Not speaking brains or anything, but it’s another diversion risk that we kind of looked into. And unfortunately, morphine comes like that a lot. Is it’s always in, like, carpet jack that we receive.
Terri
Yeah, no, I remember those struggles, too, going back and forth. And I remember when I first found out that they didn’t use them, I’m like, well, how do you get the med out? And then I’m like, what?
Tyler
Yeah, they’re like, watch this.
Terri
Yeah, exactly. But if they do it right, then you’ve also eliminated potential infection control. Right. Because they’re not drawing out of the vial. So. Yeah, so that’s another reason if you can get them to use the carburetch like they’re supposed to. Yeah. Okay, well, that’s great. And I think, you know, I think intuitively we know these things. You know, when I’m performing deep dive audits, that’s one of the things I look at, especially in a procedural area, but really everywhere, it’s like, you know, there’s a pattern here. Diversion or not diversion, it doesn’t matter. But as I start to see the waste amounts, you know, that’s often feedback that I’ll give to the director of pharmacy. It’s like, look how much this is.
Terri
How much less would have been wasted had you had fentanyl, 50 microgram vials instead of 1/ hundreds, you know, and help them see that. And sometimes what I find, it’s a matter of there was a shortage, so they switched it out and they never went back. Or, oh, yeah, we have those in other areas, but we don’t have them in here. You know, I’ll look at that. And so it’s just kind of that team effort that somebody else is looking at it the big picture, and it’s like, oh, here’s a change you could make and you know, you’re going to save something. So, yeah. And you’ve both. You’ve addressed the diversion, Right. How to tie it back to, okay, we can save some money, we can make people happier from a workflow perspective. But then there’s the diversion piece.
Terri
Because oftentimes that’s where it starts with the waste. Because it’s easy to think that, well, it’s just going to be thrown out anyway, so I’m not really doing anything that wrong. You know, they can justify. So eliminating that piece then is good.
Kayla
And I think, because there’s so many different ways to weigh something, and I say that because I observe many different, you know, unique behaviors and things that happened. And I’m, you know, and it’s just interesting. The human aspect plays a big part in that as well. And, you know, even if you have cameras set up, you have everything in the world set up to kind of prevent, you know, people from even thinking of doing that, you know, it still happens. It happens, you know, and people think of new ways all the time. And just the way. Just having the waste, you know, prompt them to think of new ways because they’re like, hey, I have half of this left. What am I going to do with this? You know, I’m wasting this all the time. No one’s going to care.
Kayla
A little bit of this waste that’s already supposed to be wasted is going to go away. So I think that’s a key. That’s a really key piece of trying to eliminate that as much as possible.
Terri
Absolutely, absolutely. So is it safe to assume then that based on the research, the. The facilities have implemented the change, you have brought in new products that are. That are smaller strengths and implemented.
Kayla
It’s a hospital. I did this study at the research, and they have actually incorporated the smaller versions of the hydromorphone. Till this day, they are looking at the fentanyl option, but right now are keeping the risepam option. That’s just due to where they’re stalking it elsewhere in the hospital as well. They do have another unit where they do see a lot of hospice patients who do come through. And lorazepam is unfortunately, one of their more common comfort meds. They do use a little bit larger doses in there, so it would make more sense to stock that larger 2 milligram there. So, yeah, and that’s just from a, you know, a practice standpoint, you know, what is your paper population look in your hospital. And again, that was a unit I didn’t include, and so I found that out after the fact.
Kayla
And so it’s perpendicular to make those decisions based on your paper population and kind of what you see if it comes to your hospital as well. But the other two, again, hydrofoam is in play. Fentanyl is coming up next. And hopefully looking in to see kind of what that input actually looks like after a little while. It was very recent. In the past couple months they have done this, so hopefully it will produce some really great savings and reduce the waste. And we can use that as a model hospital and kind of go from there, kind of incorporate across everywhere else. So. Yeah, for sure.
Terri
Yeah. And Tyler, I believe you said that the fentanyl and then the hydromorphone kind of happened naturally after stock came back.
Tyler
Yeah. With the supply chain issues. You know, once they saw the hydromorphone sizes that we had to offer, they’re like, oh, yeah, we’re not going back to. Because wasting. And you and Kayla were saying, it’s very interesting that during COVID we had a. My wife’s a nurse, so I get to hear all this stuff firsthand. But we had a big, like, nursing shortage. Everybody was moving hospitals. So then, you know, we have nursing ratios on some inpatient units that are five to six patients to a nurse. So eliminating the need for us to waste these things lets them have more time to do patient care.
Tyler
So I’m interested to see, you know, if there’s any studies out there looking into them performing their patient care better because they’re not having to focus on waste or other, I don’t want to say mundane tasks, but tasks that, you know, we can eliminate for them. And that way they can focus more time on their patients instead of focus more times on documentation or looking into waste. And yeah, like you said, we did with the fennel, we made a huge impact on the ER and then also the inpatient care units. So they also, they don’t want to go back to the change. I did see if you guys are getting ready to implement fentanyl. Our wholesaler, it’s on back order right now, but There was a 25 mike per half mil, I think syringe.
Tyler
So they do make that, and we haven’t pushed that one yet because most of our doses are 25 and that would basically eliminate all of our fentanyl waste. But since we just got done performing all these other implementations, we want to kind of give it a break, wait a year or two, make sure that manufacturer gets a pretty good stock before we make these changes. Because otherwise if we make the change and then we run out of stock and then there’s not a lot of buy in and they just want to change back. So that was interesting. I was looking on our wholesaler, I was like, oh, hey, this is a new strength we can get. Let’s let’s do this all over again.
Terri
Yeah, that is interesting.
Tyler
Yeah, I think once you kind of get it figured out and I think it’s neat looking into informatics, looking at the data points and then you have actual real data to show the C suite or show the pharmacy directors on. This is what’s happening. This is real data. If we just change this one little thing, then we eliminate most of this stuff. And like you’ve mentioned the pacu, so the perioperative and intraoperative settings, those are pretty hard to change. We did those a lot more post study. So we did. We were kind of hesitant about it, but we provided them with 1 mil, 2 mil, 5 mil fentanyl in those areas. And then the CRNA anesthesiologist that’s performing, you know, sedation or pain management practices, they by experience can pick whatever size they think that case is going to need.
Tyler
So based on the patient specifically, and we’ve had a couple individuals, our chief CRNA down there, he kind of championed this and he’s been educating those individuals. So creating that buy in with that group, it was really nice having that person to, you know, preach that down there. Because sometimes when a pharmacist goes down there and says, hey, we want to change this and then you have providers that are in the mix, like, we don’t want to do that. Yeah, thanks for that.
Kayla
Yeah. The biggest challenge is the buy in from all the providers, you know, in.
Tyler
The cardiac math lab.
Kayla
Yeah, yeah, that’s the biggest challenge for sure. Because you know, we also utilize the little boxes, the trays to try to make it as simple as possible and you know, just in, just based on their preferences and the things that they like in the. It’s hard to change that.
Terri
So. Yeah, it is hard to change it. But if you do monitor it, then you can see who’s, shall we say, abusing that and pulling out the larger volumes, you know, when they don’t really need to. And if that’s consistent then you can.
Tyler
That’s kind of what we. Yeah, that’s what we’ve been doing is every month. I don’t have to do it as frequently now, but when we first made the change every month I would look for outliers and say, hey, this person pulled too much for this case so they’re not wasting it in a timely fashion. Anything that made them an outlier and then that individual would go and coach. Those new CRNAs is mostly when we had travelers or people who were here for a short spin of time, and then we’d get new people in. That’s when I noticed the fluctuations. So just watching the data every month and saying, hey, do you mind, you know, touching base with this person and seeing what’s going on?
Tyler
Because it may just be they don’t know our hospital practices and that it’s different from what they’re used to at their hospital.
Terri
Yeah. And that’s great. Having an advocate down in that area to help you. That is so important. Makes a huge difference. Yeah. Okay. Well, this was great information. So I think you both kind of proved what we intuitively know, but you put some numbers to it, and then that’s easier to sell the leadership on. And as you know, we mentioned just very briefly, it’s, you know, the pharmacy’s budget. So if it’s going to increase their budget, there’s got to be a reason to that something is being decreased. Right. And so hopefully leadership looks at the big picture and it’s like, okay, I won’t ding the pharmacy for spending a dollar more on those syringes because look at all of the rest, the savings and the diversion mitigation benefit and so on and so forth. Right. That’s all important. So it’s one big package. Yeah.
Terri
All right, well, thank you both for taking the time to share your research with us. I really appreciate it, and there’s a lot of good information there.
Tyler
Yeah, thanks. Terri. Nice to meet you. Kayla.
Kayla
Yeah, nice to meet you. Joel. Thank you so much for having us.
Terri
Absolutely.
Tyler
Thanks.
