WASTE NOT The potential benefits of prefilled syringes include improved safety, reduced waste and labor savings.

Are ready-to-use prefilled medications from compounding pharmacies a wise investment for your surgical facility? Coming up with the answer requires some thoughtful introspection, says Becki Allen, RN, CNOR, the nurse administrator at Apollo Surgery Center in West Melbourne, Fla.

About a year ago, Apollo Surgery Center decided to adopt a handful of anesthesia and emergency medications as prefilled syringes from a compounding pharmacy — atropine, ephedrine and succinylcholine, specifically. Safety was the key motivating factor in the decision, says Ms. Allen.

"Prefilled syringes ensure that we use one syringe for each patient every time, that we're not 'double dipping,' which could lead to an infection," she says. "This keeps us out of the danger zone. Our staff and anesthesiologist say it saves them time."

Likewise, patient safety is the No. 1 consideration for Debbie Beissel, RN, in the conversation surrounding prefilled syringes. Ms. Beissel, the CEO of the Surgical Institute of Reading (Pa.), also takes into account a host of other factors, including infection control, labeling compliance and the elimination of dosing errors, as well as reducing needlestick injuries to staff.

"From a nurse's standpoint, it is certainly nice if everything is individualized," says Ms. Beissel. "It's obviously fewer steps for the staff, and there's less of a chance of having any compromises to the vial or syringe."

Each color-coded syringe features "tall man" lettering to help staff distinguish between medications that look or sound alike, which Ms. Allen says further reduces the risk of compromising patient safety. Pharmacy consultant John Karwoski, RPh, MBA, says prefilled syringes' clear labeling and tamper-resistant packaging minimize the risk to patients and the exposure to surgical facility leaders.

"It's getting tougher and tougher to control, because of demands on time, with the nurse or the CRNA or the anesthesiologist expected to do so much these days," says Mr. Karwoski. "It's a question of: What is the standard of care coming to? That's why I think we're at the cusp now of seeing [prefilled syringes] becoming more mainstream."

DRAWN OUT You must consider many factors when deciding if prefilled syringes are right for your facility.

Burden or bargain?
Ask surgical facility leaders what's keeping them from adopting prefilled syringes, and you will likely hear a common refrain: "cost." Yes, prefilled syringes typically have a higher per-unit cost, but pharmacy consultant Sheldon Sones, RPh, FASCP, is of the mind that prefilled syringes can ultimately save money. He cites time efficiency and reduced drug shortages, as well as their ability to mitigate "the inherent waste" — and regulatory expectations — associated with using multi-dose vials in the OR.

Take ephedrine at $50 to $60 for an ampule as an example. Say you have to throw out the 3 vials of ephedrine that go unused. "You're talking $150 a day — more than $700 a week, almost $40,000 a year — just down the drain," says Mr. Sones. Compare that with ephedrine in a preloaded syringe. "It might cost $10 and it's going to have a shorter expiration date," he says, "but it's still a bargain."

Cost certainly entered the discussion for Apollo Surgery Center, but Ms. Allen says the surgery center ultimately found that prefilled syringes helped to save money on the back end. It helped staff get a better understanding of usage and ultimately control wastage.

Ms. Beissel says the Surgical Institute of Reading has a "very active" Supply Value Analysis Committee to evaluate monthly the high-dollar items for possible cost savings. In most cases, she says, using multi-dose vials per patient has proven to be the most cost-effective option, despite an "excessive" amount of wastage. An example is a medication that is dispensed in a 20 ml vial and the usual dose for an individual patient is 2 ml.

"This translates into an 18 ml waste," she says. "Obviously if you can get this medication in a 2 ml vial or syringe, that would make sense, but if the 2 ml vial costs twice as much as the 20 ml vial, the best case for the patient is to get the larger quantity and unfortunately waste it."

Medication wastage is a big concern, she says, because "there are many people who do not have access to the medications we are discarding."

Another cost consideration with using prefilled syringes is their 90-day shelf life. Most medications in vials have a much longer shelf life, many times a year or more. Even so, Mr. Sones believes "it's a matter of being aware of that and responding to it."

"Facilities can order in a carefully monitored and calculated way to accommodate the shorter expiration dates," he says. "At the end of the day, the elimination of wastage and avoiding some of the safety concerns far outweigh any potential drawbacks."

ANALYZE THIS An analysis of how much medication you throw out can identify opportunities to reduce costs.

How much are you wasting?
Analyzing how much medication you waste might be a good place to start, says Mr. Karwoski. Such a thorough analysis, he suspects, might reveal how prefilled syringes could help you gain back the dollar amount attributed to the wastage, despite prefilled syringes' higher cost per ml.

"If you can't go to your board and say, 'This [prefilled] syringe is $6; it's a little more money, but we'll be wasting less,' analyze it in a broader sense," he says. "What did you spend on a certain medication? How many doses did you administer in a given period, and how much of that went unused? Then calculate the same number of patients treated using the prefilled cost, factoring out the wastage, and look at the difference. When you take that difference in terms of an annualized cost to the board, it puts the value of the technology behind it out in front."

As for where to begin, Mr. Karwoski suggests starting with "a top 3 to 6" common medications — propofol, phenylephrine and succinylcholine, for example — that demonstrate the greatest savings in terms of shelf life by virtue of their stability at room temperature.

Gaining traction
Although Apollo Surgery Center has had some success with a trio of medications as prefilled syringes, Ms. Allen says the facility does not plan to expand the lineup. She adds, "I think we're in a good lane."

Mr. Karwoski says more and more ambulatory surgical centers like Ms. Allen's are mulling — and even embracing — the option. Even so, he says, "It's going to be a long time before you have an anesthesia cart stocked with all prefilled syringes."

Mr. Sones says issues other than cost might be hampering broader acceptance. As these products are provided by FDA-registered compounding pharmacies, he points to the deadliest medication contamination case in U.S. history (osmag.net/jsns4u). The New England Compounding Center, a family-run pharmacy in a suburban Boston strip mall, singlehandedly sparked a nationwide outbreak of fungal meningitis by selling tainted vials of injectable steroid. The toll was staggering: 64 dead and more than 750 sickened.

"Because of what happened in Massachusetts 2 years ago, there has been a natural reluctance, but that's improving," he says, adding that new guidelines and standards, as well as FDA enforcement, should temper these concerns. "Hospitals have embraced it, and if hospitals do something, it tends to filter down to ASCs. The track record is already established, and if that track record continues to be good, you're going to see it gain more traction."

Next steps
Are prefilled syringes a better fit for your facility than multi-use vials? When vetting potential vendors, take the advice of Ms. Allen — someone who has already taken the next step.

• Do your research. "Visit the [compounding pharmacy] you might use, or have your consultant pharmacist visit to tour the facilities to make sure you're using a company that's reputable. We've never had a company deny us yet."
• Be prepared. "You have to work through the over- and under-ordering dilemma till you figure out what your pace will be. In the beginning, it was more difficult, so you might over- or under-order till you're better in tune. We were able to tweak what our par levels needed to be, which gave us a better handle on our lead-time."
• Focus on high-dollar medications. "With something like lidocaine for patient IV starts, it's a low-cost item, so if we're wasting a low-cost item, it's a part of doing business. High-dollar medications are a different story." OSM