Abstract:

Diabetes and asthma impact the lives of millions of Americans in the United States today. Insulin is used to manage inpatient diabetes care when patients are hospitalized, and insulin at UCSF’s adult hospital is delivered through multi-dose insulin pens. At times of transition (such as transfers to other patient care units), patient-specific bulk medications such as, but not limited to, insulin pens and multi-dose inhalers are frequently wasted because of incomplete bulk-medication transfer across units. Bulk medications are either dispensed from the inpatient pharmacy or automatic medication-dispensing Pyxis devices, and multiple pens or inhalers can be pulled from different Pyxis locations across the hospital. This often leads to duplicate insulin pens or inhalers being dispensed resulting in increased waste. Another common source of waste involves inappropriate storage of a patient’s bulk medication in the patient room, which leads to nurses pulling new medications when an existing one is already at the patient’s bedside.

Medication waste has a significant impact on the healthcare budget and detrimental effects on the environment. These duplicated, inefficient practices generate waste and environmental burdens, adding unnecessary costs to the patients, our institution, and the health system at large. Additionally, streamlining bulk medication utilization will increase equity and resiliency in our health system considering the ubiquitous drug shortages, the limited access to these lifesaving drugs, and how diabetes and asthma disproportionally affect communities experiencing health disparities.

In the future, we can evaluate avenues to enhance health equity and access to critical medications while simultaneously minimizing waste and optimizing patient outcomes. Through comprehensive assessment and strategic planning, we can identify opportunities for dispensing medications in a manner that addresses disparities in healthcare access such as with patients who cannot afford insulin/inhalers or are discharged at a time of night when they have limited access to pharmacies. By implementing sustainable practices and leveraging innovative solutions, we can reduce waste, decrease costs of paying for proper disposal of partially used medications (hazardous pharmaceutical waste), reduce carbon emissions, and ensure that every individual has equitable access to essential treatments, thereby promoting healthier communities and improving overall well-being.

TEAM - Core implementation team members and titles

Esther Rov-Ikpah, MS, RN, CDCES, Diabetes Care and Education Specialist

Kethen So, PharmD, MBA, DPLA, BCSCP, FCSHP, Pharmacy Manager

Jimin Lee, PharmD, BCPS, Pharmacy Supervisor

Meghan Talbert, MSN, RN, AGCNS-BC, CDCES

Lisa Hartmayer, MSN, RN, ANP-C, CCTN

Gina Stassinos, PharmD, Staff Pharmacist, Emergency Department

Robert Rushakoff, MD, Clinical Professor, Diabetes and Endocrinology

Samantha Scott-Marquina, MS, RCP, Director of Respiratory Care Services

Brian Daniel, RCP, Respiratory Care Clinical Specialist

Kaiyi Wang, MS, Sustainability Analyst, Sustainability

Seema Gandhi, MD, Clinical Professor, Anesthesiologist and the Medical Director of Sustainability

Problem: 

Insulin pens and inhalers are common bulk medications used for inpatient management of diabetes and asthma, respectively. Hyperglycemia affects up to 38% of hospitalized patients, most of whom will require at least one type of insulin (Malcolm et al., 2018). Insulin pens are dispensed from automatic medication-dispensing Pyxis devices, and multiple pens can be pulled from different device locations across the hospital. This increases the likelihood that a new pen will be pulled when a patient is transferred to a different location, rather than ensuring that the existing medication is properly transferred with the patient. Waste can also occur when pens are left at the patient’s bedside instead of being placed in the appropriate location in the room or medication room, which can lead to practices of pulling new pens when an existing one is already available. We consider a duplicate insulin pen as waste when a patient has more than 1 insulin aspart and 1 insulin glargine pen pulled from the Pyxis during the hospital stay. Based on FY23 data, 4764 insulin apart pens, and 2272 insulin glargine pens were considered duplicates, which amounted to $549,838 in wasted cost (Table 1). Similarly, depending on the inhaler, it is dispensed from inpatient pharmacy or the automatic dispensing Pyxis machine. Duplicate inhalers dispensed amounted to $79,003 in wasted cost (Table 2). The most widely dispensed meter dose inhaler uses a powerful greenhouse gas that contributes to climate change (Wilkinson et al., 2020). These wasted bulk medications pose significant financial and environmental burdens on our health system.   

Table 1. Estimated wasted cost for insulin Aspart and insulin Glargine pens that are used for in-patient diabetes management based on FY23 data

*Further data review is needed to consider readmitted patients in FY23 to capture exact duplicated/wasted pen data.

Table 2. Estimated wasted cost for different types of inhalers that are used for in-patient asthma management based on FY23 data

Bulk medication waste is not a problem exclusive to our health system. A 240-bed community hospital in the Johns Hopkins Health System reported on average 1 insulin aspart pen and 0.8 insulin glargine pen were wasted per patient. A statistically significant reduction in the number of pens wasted per patient and annual cost savings of $66,261 were documented after a series of workflow interventions. (Najmi et al., 2021). Similarly, a sampling study conducted at Fraser Health in British Colombia reported that 19.3% of patients had at least one duplicated inhaler, which resulted in a loss of $5,151.12 among the 189 sampled patients. (Aeng et al.,2020). Both studies indicate that bulk medication waste is a widespread issue in in-patient management and substantial financial savings can be achieved with focused interventions.

Gaps:

While reviewing the workflow at UCSF, we observed that the current practices for bulk medication prescription and use result in significant duplication and waste. These practices include a lack of standardized protocol for medication transfer between locations and inconsistencies in bulk medication placement at the patient’s bedside.

Major contributing factors include inconsistent workflow, lack of education regarding proper bulk medication transfer protocol, and lack of consistency in hand-off documentation and oversight.

1. Bulk medications are sometimes misplaced at patients’ bedside and are not returned to the cassette in the med room.
2. Frequently, medications are not packaged in medication transport bags and handed to the transport team. There is no standardized process of handover to the receiving team in the new unit.
3. In some units, we observed that medication transport bags were not present or not accessible.
4.  Inconsistent documentation of medication transfer in the Transfer Navigator in EPIC
5. Lastly, when pulling new insulin pens or inhalers from the pyxis device, reminders to verify existing medications pulled are lacking.

Targets:

With the support of our executive sponsors, the Caring Wisely team, and the dedicated efforts from our team, we have set targets for this project to:

S:  Reduce the insulin pen waste by50% and reduce the number of wasted multi-dose inhalers for all inpatients by 50% by June 2025

M: We will be working with Pharmacy to track dispense data and duplication ordering monthly.

A: We are confident that our multidisciplinary team through the education of staff and transport teams, working with the Epic build team, and periodic audits and feedback over the year of the award, this project will be impactful from a financial and environmental perspective.

R: Per CDC, in the last decade the incidence of diabetes has increased from 10.3% to 13.2% in Alaska native and non-Hispanic blacks, and similarly the incidence of asthma exacerbations related to wildfires and poor air quality has increased. The need for these bulk medications will only go up and the efforts to decrease waste are crucial.

T: We have started conversations with multidisciplinary stakeholders and plan to continue this work across the health system. Support and focus from Caring Wisely will be integrative and a key center point needed to integrate the data collection and interventions for a sustained change in practice.

I:  UCSF prides itself in serving a diverse and marginalized population not only in California but from across the country and efforts to decrease insulin waste and MDIs, which contribute to cost and emissions reduction, are very timely.

E: Our project focuses not only on reducing financial waste at UCSFH but also tackles a crucial topic of decreasing emissions from US healthcare, where 20 % of emissions are attributed to pharmaceuticals and chemicals.

Interventions:

Through an established workgroup and prior meetings, we have assembled a diverse group of team members that include representatives from Pharmacy, Diabetes Management, Nursing, Respiratory Care, Emergency Department, and Sustainability. Each team member will bring their unique perspectives with respect to their roles to engineer effective solutions for process improvement. Dr. Seema Gandhi, who previously received a Caring Wisely award in 2020, has extensive experience in successfully implementing sustainability-related quality improvement projects and will be a huge asset and provide leadership for this project.

The initial stage of the project will focus on evaluating the medication transfer process through audits and education of existing and new staff on awareness of the problem and standard protocol. Stakeholders’ interviews will be conducted to identify critical points of inefficiency in the transfer process that lead to waste. We are proposing a multi-prompt approach from education, physical, and digital reminders, to EHR modifications. Some of the modifications have already been implemented (in italics) as part of the pilot.

1. Added alert message “Check for existing insulin pen(s)” when pulling insulin pens from Pyxis (Implemented on 10/17/23)

2. Added medication rows to the Transfer Navigator (Implemented on 11/14/23)

3. Moved Handoff/Receiving row under “Patient Belongings” for more visibility in the Transfer Navigators and added this row to the Oncology units (11L, 12L) (Implemented on 1/9/24)

4. Nursing education on medication transfer protocol and cost awareness (Annual Review Module created for all inpatient Adult RNs, implemented on 10/1/23, reinforcement required). Presented at Staff meetings across the medical center to direct care staff RNs (17 unit staff meetings to ~510 direct care staff RNs including unit leaders).

Our future efforts will be aimed at:

1. Education of nurses and transfer support staff via in-person presentations at staff meetings in Emergency Rooms, ICUs, PACU, and inpatient units. We will create a video and a voiceover presentation that will be accessible to all nurses and staff. Furthermore, we will work on signage for a transfer checklist.

2. We will also track the utilization of the transfer navigator during the transfer of patients and conduct focused education to improve the utilization of the Transfer Navigator for the documentation of medication transfer.

3. Evaluate processes for onboarding new staff regarding training on medication transfer processes.

4. Implement signage in the medication room to return bulk medications to cassette and transfer patient bulk medications when transferring patients.

5. PCAs are vital to the success of this process and educating and empowering them to ask “Are there medications I need to take to the new unit” will ensure a second tier of check.

6. Establish a respiratory care-driven bronchodilator pathway to ensure timely and clinically appropriate transitions to bronchodilators.  

7. Establish a Pyxis/MAR clinical alert when dispensing inhalers

8. Educate Respiratory Care Practitioners on medication transfer protocol, cost, and environmental impact awareness of MDIs.

Potential barriers to implementation include resistance to workflow change from staff and competing priorities, especially for EPIC modifications. However, with increasing awareness and education surrounding this issue, we anticipate that we will have adequate support from staff and leadership to achieve the project targets. We do not anticipate any adverse outcomes associated with our proposed interventions.

PROPOSED EHR MODIFICATIONS

1. Addition of a Best Practice Alert (BPA) that triggers when nurses release a transfer order and will prompt the nurses at the receiving end to check for transferred medications when the patient arrives at the new unit. EHR modification options will be discussed with a multidisciplinary team of stakeholders to ensure adoption and compliance. Members of our team have experience and success in creating a BPA to decrease anesthesia gas consumption that has been adopted nationally.

2. Currently version of the PACU navigator lacks a medication sent/receive tab, we will plan to add “Medications sent/Medications received” rows in the PACU navigator to correspond with the newly improved Transfer Navigator for consistent documentation across all patient transfers in the hospital.

RETURN ON INVESTMENT (ROI) - Estimated direct cost savings and/or revenue enhancement to the health system from the proposed project

Table 1. Cost savings projection based on FY23 insulin pen and multi-dose inhaler waste data when achieving the targeted goals of 50% reduction.

Based on FY23 estimated waste data from insulin pens and multi-dose inhalers, with a conservative estimate of a 50% reduction in waste for both medications, a total saving of $314,420 can be achieved at a minimum

In addition, during our detailed observations, we might identify waste opportunities in other bulk medication waste, such as eye drops and compounded drugs, during the project which can be targeted during future endeavors.

There are other financial and environmental benefits in reducing bulk med waste disposal. Medication such as insulin pens are considered hazardous waste and must be disposed of in the black bins to be incinerated. The cost savings associated with decreased hazardous waste disposal will be determined as part of the proposed work.

Sustainability:

We reviewed preliminary results for the interventions that were already in place. For November 2023, the percentage of insulin pen duplicates was 33.4%, compared to 46.2% for FY23, and the total wasted cost was $25,895 versus the monthly average of $45,820 for FY23. This indicated an encouraging improvement from our baseline assessment.

Ongoing monitoring of the interventions will be conducted by the Diabetes Care and Education Specialists, who will report back to the existing committees for improving inpatient diabetes management (Diabetes Champion group and Inpatient Diabetes Management committee). Existing project leads will continue leading this work after project completion, and data for trends of insulin pen waste will be evaluated quarterly to assess the efficacy of the interventions. The Director of Sustainability and her waste reduction team will continue audits of the new process.

Budget:

Signage for all Medication rooms: $2000

EHR analyst support: $5000

Lead clinician time support: $20000

Research Analyst support: $5000

Informatics support: $5000

Creating educational material: $8000

Conference dissemination and publication support: $5000

Total Budget Requested: $50,000

References:

Malcolm, J., Halperin, I., Miller, D. B., Moore, S., Nerenberg, K. A., Woo, V., ... & Diabetes Canada Clinical Practice Guidelines Expert Committee. (2018). In-hospital management of diabetes. Canadian journal of diabetes, 42, S115-S123.

Najmi, U., Haque, W. Z., Ansari, U., Yemane, E., Alexander, L. A., Lee, C., ... & Zilbermint, M. (2021). Inpatient insulin pen implementation, waste, and potential cost savings: a community hospital experience. Journal of Diabetes Science and Technology, 15(4), 741-747.

Aeng, E. S., Dhaliwal, M. M., & Tejani, A. M. (2020). A cautionary tale of multiple‐dose drug products: Fluticasone and salmeterol combination inhaler waste. Journal of Evaluation in Clinical Practice, 26(6), 1699-1702.

Wilkinson, A.J.K., Anderson, G. Sustainability in Inhaled Drug Delivery. Pharm Med 34, 191–199 (2020).