Short-term albumin crisis leads to long-term savings
Team builds new improvements on initial gains
Critical, nationwide albumin shortages a coupleof years ago triggered quick substitutions and saved $200,000 a year for Sarasota (FL) Memorial Hospital. Led by the department of Pharmaceutical Care, the move met with eager acceptance by head nurses in the coronary surgery units which used 90% of the albumin. Albumin is the blood plasma product often used to replace loss of blood volume during surgery.
That crisis set the stage for improvements in pharmaceutical care at the 900-bed hospital, and the action hasn't stopped since. But make no mistake, says Pharmaceutical Care's clinical pharmacist Amy Davis, RPh, each change requires drug expertise and a lot of diplomacy.
Serendipity speeds the change
As albumin costs climbed from $17,500 in December 1996 to $26,500 in January 1997, "we started asking ourselves `who really needs albumin?'" explains Davis.
Fortunately, the hospital had just joined Boston-based Institute for Healthcare Improvement's Breakthrough Series Collaborative on Improving Prescribing Practices, a nationwide peer group network of providers and quality professionals working to upgrade pharmaceutical care. So Davis put the question out to other collaborative members around the country and found the answers she needed within six weeks. "The literature supported treatment of regular postoperative patients with fluids like saline or hetastarch, even for open heart surgery," she says.
Even though the case for cost-effective albumin substitutes was already laid out,1 "we had never faced a severe shortage before, so we always used albumin," Davis says. "There were standing orders, and it was always on the shelf."
Upon seeing the evidence for alternative fluid replacements, and in the face of absences of albumin, the physicians adopted the alternatives. But not happily. They regarded the move as temporary. With the nurses, it was a different story.
"When our team presented the case to the head nurses on the open-heart care team," Davis recalls, "they said the only reason they always used albumin was that they had always done it that way." With the evidence for alternatives in front of them, their acceptance of the change was practically unanimous. The standing orders for albumin fluid replacement changed immediately. (For a look at how costs dropped, see graphic "Monthly $$ for Albumin," p. 84.)
Pharmacists, nurses, and some of the physicians wrote guidelines for albumin use and posted them on the intensive care units. Today, albumin is the third choice rather than first choice for fluid replacement. Consequently, its use has diminished to the point that it's no longer kept in the units' floor stock. (For the guidelines and supplemental clinical decision criteria, see charts "New Fluid Resuscitation/Replacement Guidelines," p. 85 and "Clinical situations in which albumin would be indicated," above.)
"Almost all of our gains have been nurse-driven," Davis says. She adds that the albumin case initiated conversations among the nurses about other pharmaceutical changes that could save money without compromising patient outcomes.
One month after the change to albumin alternatives, the nurses reported no difference in patient care. They saw no reason to switch back to albumin for routine use. As for physician reactions, Davis describes them as disbelieving. A typical comeback: "One month is not enough for credible results; it's a fluke."
Then, following five months of favorable patient outcomes, the pharmacy team turned to the Quality Improvement department for comparative data to document before and after outcomes. For example, they compared length of stay and tube drainage complications for intravenous fluid replacements. "We showed [the data] to the physicians and said `look this is not a fluke,'" she adds. That convinced enough staff to make the change stick.
Davis attributes some of the difficulty in securing physician buy-in on this and other practice changes to ignorance of solid evidence for better alternatives. Another factor is resistance to change - which is not limited to doctors.
Looking back at the albumin project, Davis recognizes it might have been easier to win physicians' support sooner if the pharmaceutical team defined baseline patient outcome measures for later comparisons. "But the shortage made us act fast," she says.
Holding on to the gains involves regular tracking of fluid replacement outcomes through Davis' chart reviews. When albumin use creeps up, she visits the respective nursing unit and reviews the guidelines. She attributes the lapses to occasional "dysfunctions in our information dissemination process." Staff simply forget about the new practice, or new people don't know about it.
Now the spotlight is on the hospital's drug formulary. Davis and colleagues are reviewing the number of drugs in each category. Recently they looked at antibiotics. Davis explains that the new family of quinolones is widely deemed a major improvement over many earlier antibiotics. With the addition of quinolones, Davis explains, they've whittled their formulary from nine to two types of antibiotics.
Formulary consolidation saves time and space, Davis says. Loading additional meds into the dispensing units on the nursing stations takes two to three hours. The dispensing units also have limited space. So if the formulary contains more drug types than the units hold, some of them have to be stored in the pharmacy. When an order for such a drug comes up, administering it is delayed while someone treks to the pharmacy to pick it up.
While the physicians are more agreeable to formulary reduction than they were to albumin alternatives, they aren't initiating the changes. Again, the nurses are at the forefront, Davis observes. "They're always asking where else they can save on drug costs."
[For further information on the albumin alternatives project and on consolidating drug formularies, contact:
· Amy Davis, RPh, Department of Pharmaceutical Care, Sarasota Memorial Hospital, 1700 Tamiami Trail, Sarasota, FL 34239-3555. Telephone: (941) 917-1319. Fax: (941) 917-1637. E-mail: [email protected].]
Reference
1. Vermeulen LC, Ratko TA, Erstad BL, et al. A paradigm for consensus: The UHC guidelines for the use of albumin, nonprotein colloid and crystalloid solutions. Arch Intern Med 1995; 155:373-379.
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