I read an article in the National Post recently regarding a clotting glue that can be replaced by manual pressure by the surgeon. The cost savings was $364.00 per use of this product. I applaud the hospitals for the outcomes of their grass roots efforts, which resulted in financial savings, and enhanced wait list management. This type of thinking allows our healthcare dollars to be effectively used elsewhere.
Sometimes we have to own up to practices that encourage waste, before we can problem solve solutions.
Take Long-Term Care homes in Ontario, and medication waste for example. To preface this, there are strict regulations regarding medications in homes, under the governance of the Ministry of Health and Long-Term Care (MOHLTC). Pharmacists are also bound by legislation and their governing body regarding dispensing.
In the old days before “Long-Term Care” was the vogue word, medication dispensing practices were different. I remember working in a hospital in the late '70's where a med cart with glass holders was used to dispense pills. Each patient’s meds were written on colour coded cards based on their frequency. As the assigned medication nurse, duties included checking the cards, and pouring the medications into the assigned cups. There was a high level of responsibility and accountability, in the preparation and distribution of meds, as well as the patient assessment and review. But we were given sufficient time to do a thorough job. Quite archaic in comparison to ongoing improvements to efficiency in today’s practices. After all, today the medication pass needs to be expedited, because of limited staff, and all the other jobs expected of a Registered Team Member.
Today, medicating people is a whole new practice. In Long-Term Care, pills often come in long strip packaging, small connected pouches with the Resident’s medications neatly packed in labeled pockets: pre measured, and pre poured by machines at the pharmacy, with appropriate labels intact. The drugs are supplied in weekly quantities. The pills are removed from the pouch at the appropriate time, leaving the rest of the chain holding the remainder of the weekly pills. It is still incumbent upon the nurse to review each pill, and assess the client pre administration, to insure the pills are timely, appropriate, and correct.
Sounds much easier, and more efficient than being locked in a tiny nook, preparing pills every four hours or so, don’t you think? But here’s where the waste comes into play.
When residents have a change of health, medications often require review, and those bundles with a week’s worth of drugs now require modification. For safety, the packs do not have the capability to be opened, and secured shut again. Hence, that plethora of pills, in a strip pack requires adjustment.
It seems some homes discard the rest of the week’s worth of medications and receive a brand new set for the remainder of the week. These pills undergo a rigid drug destruction practice.
Let's qualify this further: So if I am taking 8 pills daily and 5 days are left, there may be a discard of 40 pills.
Some homes reduce waste with a procedure that alerts the nurse during the med pass to remove the discontinued drug. These homes receive the newest medication via a companion pack. In other words, the additional pills arrive in a separate vessel to be given at the appropriate time. This practice continues until the next week, when a new strip arrives. Hence the only pill discarded is the one not in use.
Arguably some may say this increases the risk of error...but does it?
Speaking of waste, what about controlled pain medications like narcotics? Residents receive pills or injectable meds specifically for their own usage. Often as a palliative care measure, these injectable meds reduce pain and discomfort when someone is dying. Once the stock of drugs have been sent to manage a Resident's pain, they become part of their personal medication stock, just like at your own residence. Alas, I may pass away shortly thereafter, leaving behind a plethora of medications. Again, because of strict practices, and legislation these medications become disposables.
Not to mention cost issues, problems arise when some of these meds have been affected by manufacturer shortages, so in fact at times we may be destroying drugs that are needed elsewhere.
Now, I acknowledge and understand that medication safety is paramount for the well being of our elders and everyone. The ISMP (Institute for Safe Medication Practice) an “independent, national, not for profit organization, committed to the advancement of medication safety in healthcare settings,” is instrumental in advocating for safe medication practices. Their role in analyzing medication incidents has lead to some powerful changes and quality initiatives. Long-Term Care homes are part of the community they serve. https://www.ismp-canada.org/index.htm
I also understand that there are rules and regulations regarding medications in LTC, with affiliated governing bodies. We can all agree that managing medication waste appropriately and safely, needs to be the priority. But how can we offset some of the waste?
How about using some simple grass roots approaches like the hospitals mentioned by the National Post?
- Are we taking enough time to review medication profiles with residents and families upon admission to help reassess needed medications? Why not include a pharmacist at the mandated six- week interview where the Physician and team assembles, with the new admission and their family. This would allow for additional 1:1 consultation, to ask questions, recap the physician's medication orders, and meet privately with families. The pharmacy is contracted by the home after all, so let’s reduce the amount of pills ingested wherever prudent and build a pharmacist/patient relationship from the start
- If a resident requires palliative medications, pain control is paramount. But, perhaps sending narcotics lasting for a shorter window of time is more sensible. Should the quantities dwindle, replacement medications can be sent to homes to avoid waste, and insure the resident is comfortable: no interruptions. Reducing drug destruction and waste just make sense.
- Medication delivery is a time consuming process. Elders entering into LTC homes are more acutely ill with more complex needs than a decade ago. If there were more staff working in LTC, this would allow for more time to provide care, and allow additional time to complete the medication pass. Perhaps we need more collaboration with Long-Term Care employees and contractors: Registered Staff, Physicians, Pharmacists, as well as the ISMP and legislative bodies, to review waste of medications and ascertain best practice ideas across the sector. There seems to be variances in homes when medication packs are discarded. Why is that? What is best practice when the daily strip should be replaced?
- How about inviting Pharmacists from those contracted pharmacies to conduct general family education regularly, and especially when contentious medication issues arise in the press? The ongoing antipsychotic usage debate in LTC, would be an excellent example where general education could be provided for the benefit of all. Let’s be proactive about education and keep the lines of communication open, so news stories don't precipitate a demand to eliminate medications without a formal discussion
- If there are issues with medication shortages, how can we better address medication management, to avoid undue waste by one sector, so another has the drugs required?
I am certain there are more solutions to harnessing medication waste in Long-Term Care homes, but grass roots actions are a starting point. Heightened reviews of individual medication profiles from admission, increasing education, finding best practice to reduce daily waste including collaboration with staff and governance, reducing narcotic waste, and addressing staffing complements to enhance efficiency, is a great start.
We may choose to keep the lid on this issue, but those hazardous waste pails with legally deactivated drugs have to be discarded... somewhere.