A propofol disposal initiative at Mayo Clinic in Rochester, MN, reduced the number of full propofol bottles in an ICU waste bin to zero, successfully addressing drug diversion at the facility.
Initially, 44.1% of propofol bottles in waste bins were full before the intervention. The effort was replicated in other units where propofol use is common — and diversion is tempting.
The initial project was aimed at reducing the risk of drug diversion and diminishing the environmental effect of medication discarded down the sink, explain Michael T. Ring, MSN, RN, nurse manager, and Dale M. Pfrimmer, MS, RN, hospice coordinator. Their work was supported by the American Association of Critical-Care Nurses.
Charcoal and Bottle Openers
The intervention team selected the ICU with the highest propofol use and replicated the disposal process used in Mayo Clinic operating rooms. In those units, staff use activated carbon pouches and bottle cap removal tools to empty and neutralize the propofol containers.
The team provided some of the same tools in each ICU room at the nurses’ workstation, Ring and Pfrimmer explain. They conducted audits of unsecured waste bins before the intervention, and they surveyed staff on institutional policy awareness and disposal processes before and after the intervention. The results of the initial survey indicated significant concern for drug diversion risk.
“Propofol disposal in the ICU had been identified as an opportunity for improvement, and a risk point for drug diversion, by our internal multidisciplinary drug diversion prevention team,” Pfrimmer says. “When walking through the ICUs, we noticed propofol not being disposed of properly, with full and near-full bottles sitting in glass waste bins. Photos of the full bottles were used in the education modules for staff and helped drive the need for change home and gain end user buy-in.”
The team sought approval for this improvement project from the multidisciplinary drug diversion prevention team. They used a quality improvement structure, the Plan-Do-Study-Act format, to measure the success of the project. They met with the ICU nurse managers to gain their support and buy-in before meeting with the ICU nursing staff.
Some Challenges
Ring says the project went smoothly, although a few notable challenges arose during implementation.
“We successfully went into each patient room in the cardiovascular surgery ICU and installed the bin and bottle-opening tool next to the nurse’s workstation. Nurses who were working on shift that day were very engaged and assisted with locating the bins in the ICU room and asked clarifying questions to the process,” Ring says. “Shortly after installation, nurses began disposing propofol in the activated carbon pouches with success, and the pouches filled up quite quickly.”
Several days after installation, the team received word the now-heavy bins were falling off the workstations because the adhesive was not strong enough, and some of them were going missing from the rooms.
“We later discovered that environmental services was removing them from rooms during cleaning as they were not yet familiar with these and did not know to leave them in-room, especially as they were not secured to the workstations following the adhesive failure,” Ring explains. “In response, we immediately communicated with the staff that a solution was coming. We obtained stronger adhesive and reinstalled all the bins in each patient room.”
The team replaced bins/tools in rooms where they were missing. This also provided a unique opportunity to educate additional staff in the rooms and engage them in the process.
In a positive twist, the sight and sound of the bins dropping off the workstations created quite a “splash” and helped create additional awareness for the pilot project, Ring says.
Most Bottle Caps Removed
Widespread adherence to this disposal process was demonstrated by the removal of propofol caps in nearly 90% of bottles audited, Ring says. The remaining 10% of bottles were empty, and therefore did not need their caps removed to dispose of the unused contents.
“Overall, pre-pilot we discovered over 44% of discarded bottles contained at least 5 mL of propofol. These bottles were found in unsecured waste bins in the ICU rooms, where a staff or family member could open the bin and retrieve full or partially full propofol bottles,” Ring explains. “Following our intervention, we found 0% of discarded bottles to contain propofol during two post-intervention audits, both at one month and six months after intervention.”
The team aimed to reduce a key risk point that could lead to drug diversion and/or harmful events in the future, Ring says. Although this project did not completely eliminate all areas of risk associated with propofol or other controlled substances, they determined it was a step in the right direction — a step already performed in the operating room practice.
“We learned that staff engagement was key, through gathering feedback through surveys and all-staff meetings, one-on-one educational sessions at the bedside during installation twice, and marketing flyers and email communications to provide the background and the ‘why,’” Ring explains. “We also learned, chiefly from staff feedback, that this process had to be easy and within the nurse’s workflow to be successful.”
Previous practice included disposing of propofol down the sink or in the waste bin directly, so the team had to design a process that was as easy and direct as possible, Ring says. They also determined having the right tools, including a specially designed bottle cap opener and activated charcoal pouch, installed at the right location (with strong adhesive or screws), created a sustainable solution that remains in use.
Multidisciplinary Approach Key
Pfrimmer notes the multidisciplinary approach was key, as nursing, pharmacy, and supply chain all played important roles in this project.
“We would encourage others to critically examine their practice, especially high-risk areas such as operating rooms, procedural areas, emergency departments, and ICUs for risk points for drug diversion, and implement change to mitigate those risks,” he says. “Be proactive to identify risks rather than reactive after a diversion event.”
Solutions should fit within clinical staff workflows without adding non-value-added steps. Making it easy for the end user to do the right thing was key to this project’s success.
“Having the bottle-opening tool available, and tethering it to the container holding the charcoal-activated pouch, ensured the tool would not go missing, and increased the sustainability of the project,” Pfrimmer says.
A propofol disposal initiative at Mayo Clinic reduced the number of full propofol bottles in an ICU waste bin to zero, successfully addressing drug diversion at the facility. Initially, 44.1% of propofol bottles in waste bins were full before the intervention. The effort was replicated in other units where propofol use is common — and diversion is tempting.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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