Protocol Power

Vol. 18 • Issue 2 • Page 24

Financial constraints govern medicine today as much as science. Like all respiratory care departments, we are constantly on the lookout for ways to improve patient care in the most cost-effective way possible.

One way our department has achieved this goal is by implementing a common canister protocol at our 250-bed community hospital. By allowing the use of a single metered dose inhaler among multiple patients, this relatively unknown protocol has saved our facility thousands of dollars and reduced the costly burden of wasted medication.

Though we are pleased with the results of this protocol in our facility, implementing a common canister protocol requires thoughtful analysis and deliberation.

Confronting the challenge

In early 2007, a routine review of our hospital’s respiratory medication usage indicated we were spending twice as much money on fluticasone propionate and salmeterol inhalation powder than on all other MDIs and dry powder inhalers combined – $88,663 versus $43,725. Further analysis of our medication usage revealed the primary cause for the high expense was a combination of the medication’s cost and 18,920 doses of wasted medication.

On the other hand, our physicians, respiratory therapists, and patients noted a positive clinical outcome with the drug. As we began searching for ways to reduce our costs without eliminating the medication’s use, we learned it was now available in an MDI formulation.

We theorized that if our facility began using a common canister protocol for this drug and our other MDIs, we could virtually eliminate wasted medication and significantly reduce costs. Using average dosages and treatment frequencies for all of our MDIs, we calculated that a staggering 158,736 doses (dose = 1 puff) of these medications were wasted during our fiscal year 2007. This correlated to approximately $103,000 in wasted expenditure.

Using prior studies for reference, we established the following common canister protocol in our hospital: 3-5• Pharmacy delivers MDI medication to locked medication drawer in patient’s room.

• RT delivers MDI via valved holding chamber device and tracks the number of doses given.

• Once order is discontinued or patient leaves, the outside of the MDI is wiped using a disinfectant cleaning solution and is returned to pharmacy.

• Pharmacy re-labels and reissues the MDI to the next patient ordered for therapy.

Prior to receiving approval for the common canister protocol, concerns arose about infection control, accrediting agency standards, the tracking method for doses delivered, billing issues, and increased costs caused by using the protocol.

Infection control and safety concerns

The biggest concern was the risk of spreading infection by allowing multiple patients to use the same MDI canister. Our infection control department required scientific evidence to show the risk was minimal or none at all. Fortunately, several studies showed this to be the case.6-8

In addition, we did not want to take any chances with patients who are in contact isolation or with our mechanically ventilated patients. We exempt the MDIs used on these patients from the protocol.

We next evaluated concerns about whether or not the protocol met the standards set by The Joint Commission. We specifically focused on the requirement that medications are properly and safely stored throughout the hospital. The Centers for Medicare & Medicaid Services’ definition of “se?cured” states that all medications, including non-prescription medications, should be in a locked container in a room or are under constant surveillance.

Our interpretation of this standard meant that RTs no longer could carry medications in their lab coat pockets. We found an alternative approach to stay in compliance. Our facility uses a unique medication management system in that all patient medications are delivered by the pharmacy to a locked drawer located at the patient’s bedside. Therefore, the MDI medications are kept in a locked container at all times other than when being administered to the patient.

Tracking doses

Keeping track of the number of doses used for each MDI will one day be as simple as looking at the counter built into the device. Although more MDIs with this feature are becoming available, only a few currently include counters.

As an alternative, we decided to develop our own tracking system. We designed two stickers that list the number of doses in a new MDI in sequential order. For example, an albuterol MDI contains 200 doses. The stickers used for this MDI contain the numbers 1 through 180 (minus 20 doses which we left out as a safety factor).

These stickers are placed on a zipper-lock bag that contains the MDI. Each time an RT administers a dose, the RT crosses off the appropriate number based on the amount given. When all of the numbers on the sticker are crossed off, the MDI is discarded.

Cost savings

Our facility began billing patients by the dose instead of charging for the entire MDI. Each time a dose is documented as being adminstered, the patient is charged only for that dose.

The only significant cost increase related to the need for more valved holding chambers when we changed to the MDI formulation of fluticasone propionate and salmeterol. This approximately $5,000 increase was minimal compared with the expected savings. In fiscal year 2007, our total cost of all MDIs and DPIs was $143,002. In fiscal year 2008, our total cost was $80,331, for a total savings of $62,671.

Many things must be taken into consideration when viewing our net savings, including a comparison of the total number of treatments administered each year, price increases for the medications, and the total number of patients using MDIs who were mechanically ventilated or in contact isolation.

Over the coming months, we will examine each of these factors to try to determine just how effective the common canister protocol is at reducing wasted medication and reducing our hospital costs.

However, when we took a peek at what happened to that $88,663 expense for fluticasone propionate and salmeterol inhalation powder in 2007, we learned that we cut that expense down to $50,547. Instead of using 946 DPIs, we used 309 MDIs.

For now, we are satisfied to know that by using a common canister protocol, we reduced our hospital’s cost for respiratory-related medications by nearly $63,000 and eliminated thousands of wasted doses of medication. And we did it all without one reported problem from our infection control department.

For a list of references, look under the magazine tab at

Thomas Lamphere BS, RRT, RPFT, is the former manager of the respiratory care department at Grand View Hospital, Sellersville, Pa. He is currently excecutive director of the Pennsylvania Society for Respiratory Care.