Cost-cutting meets a sacred cow: Pharmacological savings in surgery
Historically protected turf, the operating room is ripe for savings
From the moment patients are shaved until they awaken in the recovery room, they’re getting pumped full of pharmaceuticals: anti-emetics, anticholinergics, sedatives, anesthetics, volume replacements, hemostatics, and finally, narcotics. Many of those drugs are extremely expensive and, as one Michigan hospital found, some are unnecessary.
When the University of Michigan Health Systems in Ann Arbor embarked on a plan to bring its costs in line with other area institutions, the operating room (OR) wasn’t exempt. And as Julie Golembiewski, PharmD, can attest, significant cost-cutting can be done in hospital ORs without compromising patient safety.
Golembiewski, OR pharmacy team leader, says two main things drive up costs in operating rooms: choice of agents and waste. "We’ve tried to attack waste," she says. "We’ve tried to stress drawing up drugs only when you’re going to administer them." Golembiewski says vial size is an important issue, as well. She found that while multidose vials are cheaper in the short term, they cost more in the long run because unused doses tend to get thrown out.
This was especially true in the case of midazolam, the hospital’s previous drug of choice for preoperative sedation. Pharmacy technicians began to notice that midazolam vials containing 5 mg of the drug — and meant to be used for a couple of patients — were either getting thrown out or returned to the pharmacy half used. "Which is why my philosophy is to use unit-of-use packages," Golembiewski says.
But the pharmacy went one step further by putting on trial Dizak, the emulsifiable diazepam solution that can be injected without pain or threat of thromboembolism. "It is now the benzodiazepine of choice," Golembiewski says. She estimates that by cutting back on midazolam use, the hospital is saving about $40,000.
Patients undergoing surgery need muscle relaxants, and Golembiewski used some deductive reasoning to find the most economical choice.
"We’re a teaching hospital," she says. "The average duration [of surgery] is three hours. So [we asked ourselves], Why are we using intermediate-acting agents which last an hour?’" There was no good answer to that question, and that led to a switch from Veracronium to the less-expensive Pancuronium. When an intermediate agent is needed, the new choice is cisatracarium.
Inhaled anesthetics aren’t often tampered with when it comes to cost-cutting, but Golembiewski says new "low-flow" technologies use less liquid drug which is subsequently turned into a volatile gas). She says the hospital instituted a "huge" education program to promote low-flow anesthesia and added that the anesthesiology chief is a zealous cost-cutter.
But the pharmacy’s OR budget was taking its biggest hit from volume replacers: fluids given postoperatively to replace blood lost through surgical cutting. And it was in albumin that Golembiewski saw a ripe target for cuts.
"I started tracking our usage of drugs and saw we were spending big money on albumin. It kept going up, by $50,000 a year.
"We were spending close to $300,000 on albumin in the operating room," she says. "We were just giving it out like water."
Golembiewski says the free flow of albumin was stanched primarily by educating residents on its proper use. "There were lots of misconceptions among faculty that albumin was better to give than Hetastarch, but it depends on [a patient’s] needs." Golembiewski says in some cases a simple (and cheap) crystalloid solution such as Lactated Ringer’s can be just as effective as albumin.
If a colloid solution is necessary, Hetastarch is about half the price of albumin — although it does have a dose-limiting side effect of bleeding. And some patients benefit more from albumin than others. Golembiewski says cardiovascular surgeons and neurosurgeons argued vigorously to use albumin for some patients; she added that Hetastarch isn’t appropriate for some transplant patients either.
Still, the OR saw a "tremendous drop" in the use of albumin. "In eight months, time costs have dropped $107,000," she says. That projects out to an annual savings of about $160,000.
Some cost-cutting measures were less successful. Golembiewski says the pharmacy tried to find alternatives to Oxicel, a topical hemostatic, but surgeons balked at replacing the cellulose product.
"The consistency is very unique. Surgeons are very comfortable with it," Golembiewski says. Unfortunately, it costs almost $50 a vial. Alternatives to Gelfoam didn’t work either.
Painkillers and antibiotics aren’t much of a cost issue in the OR, Golembiewski says. She remembers working at one hospital in Nebraska in which regular post-op prophylaxis entailed use of a third-generation cephalosporin. "I was appalled," she says. The University of Michigan protocol calls for cheap cefazolin.
As for narcotics, morphine and fentanyl are the workhorses, she says. Neither is expensive.
Golembiewski says the entire OR staff is committed to keeping costs under control, with physicians often asking for price sheets on drugs. But in other institutions, she says, colleagues tell her that when it comes to cutting costs, the OR remains, to some extent, a sacred cow.
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