Journal of Clinical Anesthesia (2015) 27, 233–236
Original Contribution
The effect of training level on opioid utilization efficiency☆ Dmitry Roberman DO (Resident Physician), Mian Ahmad MD (Assistant Professor), Michael S. Green DO (Associate Professor)⁎ Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA, USA 19102 Received 19 May 2014; revised 29 October 2014; accepted 26 December 2014
Keywords: Utilization; Education; Narcotic and drug control; Internship and residency; Clinical audit
Abstract Study Objective: This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress. Residents request opioid from the pharmacy at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process are not trivial nor is the risk of excess opioid access. We examined if estimation of daily opioid use by residents increased in accuracy as progression through the program occurred. Materials and Methods: We conducted a retrospective analysis in the setting of the operating room examining pharmacy opioid usage. The measurements included the number of vials requested, the number of vials dispensed, and the number of vials returned. Information was stratified in our database by the level of training. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. Main Results: A total of 104 opioid requests were made that met our criteria. Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant difference exists between the number of vials requested and the number returned. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. Conclusion: In summary, our findings support the idea that residents are able to better predict opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The Accreditation Counsel for Graduate Medical Education is transitioning to an assessment system evaluating ☆
The authors report no external funding source for this study. ⁎ Correspondence: Michael S. Green, DO, Drexel University College of Medicine, 245 N. 15th St, Suite 7502, MS 310, Philadelphia, PA, 19102 USA. Tel.: + 1 215 762 7922; fax: +1 215 762 8656. E-mail address: [email protected] (M.S. Green). http://dx.doi.org/10.1016/j.jclinane.2014.12.003 0952-8180/© 2015 Elsevier Inc. All rights reserved.
residents on achieving milestones as progression through 36 months of training in anesthesiology occurs [1,2]. This Accreditation Counsel for Graduate Medical Education milestone project is designed to allow each Graduate Medical Education program to identify the behaviors and attributes that constitute the essential competencies for their specialty. There will be new challenges on behalf of faculty, program directors, and residents. The new system will be competency
234
D. Roberman et al.
and milestone based compared to the older system, which focused more on time. It is a learner-centered approach that emphasizes achieving specific outcomes [2,3]. Transition of a doctor from medical school graduation to independent practice at the conclusion of residency entails learning in multiple domains [1]. Acquisition of knowledge and skills is a gradual process. Assessment of some of these attributes is relatively easy, and methods to evaluate are well established. Development of judgment as training progresses should enable residents to become more time, resource, and cost efficient. This may be more difficult to assess and evaluate. This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress through anesthesia training. Residents request a range of opioids from the pharmacy located within the operating suite at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process is not trivial nor is the risk of excess opioid access in the operating room. We examined if estimation of daily opioid use by anesthesiology residents increased in accuracy as progression through the program occurred.
2. Materials and methods After obtaining approval from the institutional review board, we conducted a retrospective analysis of the operating room pharmacy opioid usage record at Hahnemann University Hospital from January 2012 to June 2012. This record contained routine information collected by the pharmacy per standard pharmacy record-keeping protocol. The data included deidentified patient information, the name of the resident requesting opioids, the number of vials requested, the number of vials dispensed by the pharmacy, and the number of vials returned at the end of the day. The opioids ordered included morphine, fentanyl, remifentanil, sufentanil, and hydromorphone. Information was stratified in our database by the level of training including CA-1, CA-2, and CA-3 residents. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. In our institution, for obstetric and cardiac cases, opioid acquisition is
managed under protocol; thus, the role of the individual resident in the decision making process is minimized.
3. Statistical analysis Data analysis was performed with IBM SPSS (IBM SPSS Statistics for Windows, version 20.0; IBM Corp, Armonk, NY). Mean, SD, median, and range were obtained for number of vials requested and returned by the anesthesia providers according to the level of residency training. Analysis of variance was done to compare average number of opioids requested and returned by the residents; test statistics, degrees of freedom (df), and P values were reported. Post hoc analyses using the least significant difference test were done to identify significant differences between the subgroups.
4. Results A total of 104 opioid requests were made to the operating room pharmacy from residents that met our criteria. Each request was for the number of opioid vials the resident estimated would be required to cover the caseload for a given day. Of the 104 requests to the operating room pharmacy, 50% were made from CA-1 residents (n = 52), 30% were from CA-2 (n = 31), and 10% were from CA-3 (n = 21). A total of 252 patients received these opioid during their anesthetic care. Our CA-1 residents provided care to 130 patients for whom a total of 536 vials of opioid were requested, and 260 vials were returned. The mean number of request was 11 (SD, 4), and the mean number of returns was 5 (SD, 3). CA-2 residents provided care to 74 patients and ordered 300 vials for opioids, of which 155 vials were returned. The mean number of requests was 10 (SD, 4), and the mean number of return was 5 (SD, 4). CA-3 residents provided care to 48 patients, requested 152 vials of opioid, and returned 62 vials. The mean number of requested was 8 (SD, 4), and the mean number of returned vials was 3 (SD, 3). (Table 1 and Figure) Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant different exists between the number of vials requested and the number returned (Tables 2 and 3). CA-3 residents request smaller quantities of
Table 1 Summary of number of syringes requested and returned by anesthesia providers at Hahnemann University Hospital, according to the level of residency training Level of training
No. of records
No. of syringes requested
No. of syringes returned
Efficiency
n
Mean (SD)
Median (range)
Mean (SD)
Median (range)
Mean requested/mean returned
CA-1 CA-2 CA-3
52 31 21
11 (4) 10 (4) 8 (4)
10 (4-22) 10 (4-20) 7 (1-14)
5 (3) 5 (4) 3 (3)
5 (0-15) 4 (0-13) 3 (0-7)
0.48 0.51 0.41
Training level on opioid utilization efficiency
235 Table 3 Post hoc analysis between subgroups for number of syringes requested and returned by anesthesia providers according to the level of residency training Phase
Figure
Mean number of syringes requested and returned.
medications and returned less after use. Efficiency is defined as the proportion of medication vials that were returned at the end of the day as compared to the number of vials that were requested. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. Furthermore, it is interesting that there is a statistically significant difference between CA-1 and CA-3 residents and between CA-2 and CA-3 year residents but not between CA-1 and CA-2 residents. This implies the possibility that residents become more efficient in allocating resources as they progress through training and that it may take a substantial amount of time to develop (Table 2).
5. Discussion Potential anesthesia-related waste might include items such as syringes, bottles, and vials for anesthetic drugs and airway equipment and hoses [4,5]. Another anesthesia-related concern is drug waste, which occurs when medications are drawn up but are unused and discarded at the end of the day [4,6]. In 1 study, Esaki and Macario [4] examined all opened but unused or unusable intravenous anesthesia medications collected over a 2-week period. Thirty different
Table 2 Comparison of number of syringes requested and returned by anesthesia providers according to the level of residency training Phase
Mean (SD)
95% confidence interval of mean
No. of syringes requested CA-1 11 (4) 10, 12 CA-2 10 (4) 9, 12 CA-3 8 (4) 6, 9 No. of syringes returned CA-1 5 (3) 5, 6 CA-2 5 (4) 4, 7 CA-3 3 (3) 2, 4
F test (df)
P
5.6 (2, 101)
.005 ⁎
4.1 (2, 101)
.020 ⁎
⁎ Statistically significant difference between CA-1 and CA-3 and between CA-2 and CA-3.
Mean difference 95% confidence interval P (SE) of mean difference
No. of syringes requested CA-1 vs 0.63 (0.81) CA-2 CA-1 vs 3.07 (0.93) CA-3 CA-2 vs 2.44 (1.01) CA-3 No. of syringes returned CA-1 vs 0 (0.67) CA-2 CA-1 vs 2.05 (0.76) CA-3 CA-2 vs 2.05 (0.83) CA-3
− 0.98, 2.24
.440
1.23, 4.91
.001
0.43, 4.45
.018
− 1.32, 1.32
–
0.54, 3.56
.008
0.40, 3.70
.016
drugs in 57 syringes and 139 ampules were collected from 166 cases, amounting for an average cost per case of $10.86 for discarded medications. The medications contributing to the greatest cost of waste were phenylephrine (21%), propofol (15%), vecuronium (12%), midazolam (11%), labetalol (9%), and ephedrine (9%) [4]. A separate study of 25 481 surgical patients calculated the percentage of drug actually administered to patients relative to the amount dispensed. Only 33% of succinylcholine prepared for patients was administered, and two-thirds of the prepared drug was wasted [7]. Similarly, 51% of propofol, 47% of midazolam, and 39% of rocuronium was prepared but not administered [7]. The most common reason for drug waste was need to dispose of full or partially full syringes. Pediatric anesthesiology data yielded similar results. Nava-Ocampo et al conducted a study concluding 80% of epinephrine, naloxone, flunitrazepam, ephedrine, and cisatracurium were wasted, with rocuronium and nalbuphine having the highest waste cost [8]. Medical waste is directly relevant to the practice of medicine, as it represents a misuse of resources that could otherwise be spent on patient care [5]. Operating rooms produce a disproportionately large percentage of total hospital waste. Much more can be done to better manage supply and drug waste resulting from surgical procedures [7-11]. The institution of training modules or lecture materials directed toward specific milestones may have a very positive impact on waste due to anesthesiology residents. Examples of such milestones are patient care 2: anesthetic plan and conduct; systems-based practice 1: coordination of patient care within the health care system; and practiced-based learning and improvement 2: analysis of practice to identify areas in need of improvement. Another very important issue frequently encountered among anesthesia providers is drug abuse. Despite substantial advances in our understanding of addiction and the technology and therapeutic approaches used to fight this
236 disease, addiction still remains a major issue in the anesthesia workplace, and outcomes have not appreciably changed [12]. Although alcoholism and other forms of impairment, such as addiction to other substances and mental illness, impact anesthesiologists at similar rates to other professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still an opioid [12]. Often, it is the individual who has this disorder who is the last to recognize the problem. It is, therefore, imperative that those people most likely to observe the signs and symptoms of addiction, that is, the relatives, friends, and coworkers, gain a clear understanding of the disease and understand what to do if they suspect someone may have a problem. Early identification of the affected individual can often prevent harm, both to the impaired physician and to his or her patients. Early detection is often difficult due to the compartmentalized relationships the individual may have with different members of their social structure. An important change that may be observed in an affected individual is consistently using an increasing amount of opioids or quantities inappropriate for a given case load [12]. We believe that the methodology of our study can be helpful in isolating such individuals and possibly helping in dealing with certain behaviors that we briefly touched upon. Gradual but consistent achievement of different milestones as residents progress through training is paramount. Some of the attributes are assessed objectively through standardized tests [1,3]. Learning and assessment of other attributes may not be as clear cut. Factors that help a resident decide which opioid to request and in what quantity at the start of a clinical day are numerous and involve the exercise of a complex intellectual process. Type of surgical procedure, comorbidities, patient history of opioid use, pharmacology of the drug, and plan for disposition are some of the factors that require consideration before decision regarding the amount of opioid that will be needed. We looked to see if level of training influenced residents in choosing opioids to avoid waste and improve efficiency of our pharmacy distribution system. This study may show that existing educational content within the program achieves the outcome. CA-3 residents would have greater exposure to the curriculum related to opioid diversion and abuse and cost-effective care. This may increase awareness and improve habits related to opioid utilization. The results of this study demonstrate a positive correlation between a resident's ability to predict how much opioid is needed and level of training. This report has inherent limitations due its retrospective design, and future study should use a prospective database. In addition, more representation existed
D. Roberman et al. from CA-1 vs CA-3 residents. This was due to the senior-level residents' involvement in longer and more complex cases. However, senior residents had statistically better ability to predict the absolute amounts of opioids to be used which, in fact, may be more difficult in complex patients. The CA-3 sample was not limited to few residents. A wide range of representation across the entire class existed. Furthermore, this is a preliminary report of our findings with a small sample size. Although our results have statistical significance, a large sample size will provide a better comparison of CA-1 to CA-3 patterns. A follow-up with an in-depth analysis will shed light on the dollar value of potential cost reduction as a result of modified dispensing protocols. In summary, our findings support the idea that residents are able to better predict their opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits.
References [1] Ebert TJ, Fox CA. Competency-based education in anesthesiology. Anesthesiology 2014:24-31. [2] Gambill BD. American Society of Anesthesiologist's Lifeline to Learning. Anesthesiology 2014;120:7-9. [3] Macario A. Can physician performance be assessed via simulation? Anesthesiology 2014;120:18-21. [4] Esaki RK, Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiol 2009. [5] Irwin MG, Trinh T, Yao CL. Occupational exposure to anaesthetic gases: a role for TIVA. Expert Opin Drug Saf 2009;8:473-83. [6] Weinger MB. Drug wastage contributes significantly to the cost of routine anesthesia care. J Clin Anesth 2001;13:491-7. [7] Gillerman RG, Browning RA. Drug use inefficiency: a hidden source of wasted health care dollars. Anesth Analg 2000;91:921-4. [8] Nava-Ocampo AA, Alarcon-Almanza JM, Moyao-Garcia D, RamirezMora JC, Salmeron J. Undocumented drug utilization and drug waste increase costs pediatric anesthesia care. Fundam Clin Pharmacol 2004; 18:107-12. [9] Rosenblatt WH, Ariyan C, Gutter V, Silverman DG. Case-by-case assessment of recoverable materials for overseas donation from 1318 surgical procedures. JAMA 1993;269:2647-9. [10] Rosenblatt WH, Chavez A, Tenney D, Silverman DG. Assessment of the economic impact of an overage reduction program in the operating room. J Clin Anesth 1997;9:478-81. [11] Seidman PA, Parker BM. Sharps disposal in the operating room: current clinical practices and costs. Anesth Analg 1998;87:634-6. [12] Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology 2008;109(5):905-17.
Original Contribution
The effect of training level on opioid utilization efficiency☆ Dmitry Roberman DO (Resident Physician), Mian Ahmad MD (Assistant Professor), Michael S. Green DO (Associate Professor)⁎ Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA, USA 19102 Received 19 May 2014; revised 29 October 2014; accepted 26 December 2014
Keywords: Utilization; Education; Narcotic and drug control; Internship and residency; Clinical audit
Abstract Study Objective: This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress. Residents request opioid from the pharmacy at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process are not trivial nor is the risk of excess opioid access. We examined if estimation of daily opioid use by residents increased in accuracy as progression through the program occurred. Materials and Methods: We conducted a retrospective analysis in the setting of the operating room examining pharmacy opioid usage. The measurements included the number of vials requested, the number of vials dispensed, and the number of vials returned. Information was stratified in our database by the level of training. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. Main Results: A total of 104 opioid requests were made that met our criteria. Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant difference exists between the number of vials requested and the number returned. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. Conclusion: In summary, our findings support the idea that residents are able to better predict opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The Accreditation Counsel for Graduate Medical Education is transitioning to an assessment system evaluating ☆
The authors report no external funding source for this study. ⁎ Correspondence: Michael S. Green, DO, Drexel University College of Medicine, 245 N. 15th St, Suite 7502, MS 310, Philadelphia, PA, 19102 USA. Tel.: + 1 215 762 7922; fax: +1 215 762 8656. E-mail address: [email protected] (M.S. Green). http://dx.doi.org/10.1016/j.jclinane.2014.12.003 0952-8180/© 2015 Elsevier Inc. All rights reserved.
residents on achieving milestones as progression through 36 months of training in anesthesiology occurs [1,2]. This Accreditation Counsel for Graduate Medical Education milestone project is designed to allow each Graduate Medical Education program to identify the behaviors and attributes that constitute the essential competencies for their specialty. There will be new challenges on behalf of faculty, program directors, and residents. The new system will be competency
234
D. Roberman et al.
and milestone based compared to the older system, which focused more on time. It is a learner-centered approach that emphasizes achieving specific outcomes [2,3]. Transition of a doctor from medical school graduation to independent practice at the conclusion of residency entails learning in multiple domains [1]. Acquisition of knowledge and skills is a gradual process. Assessment of some of these attributes is relatively easy, and methods to evaluate are well established. Development of judgment as training progresses should enable residents to become more time, resource, and cost efficient. This may be more difficult to assess and evaluate. This study focuses on residents' ability to predict opioid administration requirements and if improvement is made as learners progress through anesthesia training. Residents request a range of opioids from the pharmacy located within the operating suite at the start of the day based on clinical assignment. Unused and wasted opioids are returned at the end of the day. The labor and cost associated with this process is not trivial nor is the risk of excess opioid access in the operating room. We examined if estimation of daily opioid use by anesthesiology residents increased in accuracy as progression through the program occurred.
2. Materials and methods After obtaining approval from the institutional review board, we conducted a retrospective analysis of the operating room pharmacy opioid usage record at Hahnemann University Hospital from January 2012 to June 2012. This record contained routine information collected by the pharmacy per standard pharmacy record-keeping protocol. The data included deidentified patient information, the name of the resident requesting opioids, the number of vials requested, the number of vials dispensed by the pharmacy, and the number of vials returned at the end of the day. The opioids ordered included morphine, fentanyl, remifentanil, sufentanil, and hydromorphone. Information was stratified in our database by the level of training including CA-1, CA-2, and CA-3 residents. The set inclusion criterion was any surgery performed in the operating rooms that required the use of opioids. The exclusion criteria included anesthesia that required a regional block, cardiac surgeries, emergent cases, and obstetric cases. In our institution, for obstetric and cardiac cases, opioid acquisition is
managed under protocol; thus, the role of the individual resident in the decision making process is minimized.
3. Statistical analysis Data analysis was performed with IBM SPSS (IBM SPSS Statistics for Windows, version 20.0; IBM Corp, Armonk, NY). Mean, SD, median, and range were obtained for number of vials requested and returned by the anesthesia providers according to the level of residency training. Analysis of variance was done to compare average number of opioids requested and returned by the residents; test statistics, degrees of freedom (df), and P values were reported. Post hoc analyses using the least significant difference test were done to identify significant differences between the subgroups.
4. Results A total of 104 opioid requests were made to the operating room pharmacy from residents that met our criteria. Each request was for the number of opioid vials the resident estimated would be required to cover the caseload for a given day. Of the 104 requests to the operating room pharmacy, 50% were made from CA-1 residents (n = 52), 30% were from CA-2 (n = 31), and 10% were from CA-3 (n = 21). A total of 252 patients received these opioid during their anesthetic care. Our CA-1 residents provided care to 130 patients for whom a total of 536 vials of opioid were requested, and 260 vials were returned. The mean number of request was 11 (SD, 4), and the mean number of returns was 5 (SD, 3). CA-2 residents provided care to 74 patients and ordered 300 vials for opioids, of which 155 vials were returned. The mean number of requests was 10 (SD, 4), and the mean number of return was 5 (SD, 4). CA-3 residents provided care to 48 patients, requested 152 vials of opioid, and returned 62 vials. The mean number of requested was 8 (SD, 4), and the mean number of returned vials was 3 (SD, 3). (Table 1 and Figure) Comparing CA-1 and CA-3 residents and CA-2 and CA-3 residents, a statistically significant different exists between the number of vials requested and the number returned (Tables 2 and 3). CA-3 residents request smaller quantities of
Table 1 Summary of number of syringes requested and returned by anesthesia providers at Hahnemann University Hospital, according to the level of residency training Level of training
No. of records
No. of syringes requested
No. of syringes returned
Efficiency
n
Mean (SD)
Median (range)
Mean (SD)
Median (range)
Mean requested/mean returned
CA-1 CA-2 CA-3
52 31 21
11 (4) 10 (4) 8 (4)
10 (4-22) 10 (4-20) 7 (1-14)
5 (3) 5 (4) 3 (3)
5 (0-15) 4 (0-13) 3 (0-7)
0.48 0.51 0.41
Training level on opioid utilization efficiency
235 Table 3 Post hoc analysis between subgroups for number of syringes requested and returned by anesthesia providers according to the level of residency training Phase
Figure
Mean number of syringes requested and returned.
medications and returned less after use. Efficiency is defined as the proportion of medication vials that were returned at the end of the day as compared to the number of vials that were requested. Our data show a statistically significant difference in efficiency as residents progress from their CA-1 year to CA-3 year. Furthermore, it is interesting that there is a statistically significant difference between CA-1 and CA-3 residents and between CA-2 and CA-3 year residents but not between CA-1 and CA-2 residents. This implies the possibility that residents become more efficient in allocating resources as they progress through training and that it may take a substantial amount of time to develop (Table 2).
5. Discussion Potential anesthesia-related waste might include items such as syringes, bottles, and vials for anesthetic drugs and airway equipment and hoses [4,5]. Another anesthesia-related concern is drug waste, which occurs when medications are drawn up but are unused and discarded at the end of the day [4,6]. In 1 study, Esaki and Macario [4] examined all opened but unused or unusable intravenous anesthesia medications collected over a 2-week period. Thirty different
Table 2 Comparison of number of syringes requested and returned by anesthesia providers according to the level of residency training Phase
Mean (SD)
95% confidence interval of mean
No. of syringes requested CA-1 11 (4) 10, 12 CA-2 10 (4) 9, 12 CA-3 8 (4) 6, 9 No. of syringes returned CA-1 5 (3) 5, 6 CA-2 5 (4) 4, 7 CA-3 3 (3) 2, 4
F test (df)
P
5.6 (2, 101)
.005 ⁎
4.1 (2, 101)
.020 ⁎
⁎ Statistically significant difference between CA-1 and CA-3 and between CA-2 and CA-3.
Mean difference 95% confidence interval P (SE) of mean difference
No. of syringes requested CA-1 vs 0.63 (0.81) CA-2 CA-1 vs 3.07 (0.93) CA-3 CA-2 vs 2.44 (1.01) CA-3 No. of syringes returned CA-1 vs 0 (0.67) CA-2 CA-1 vs 2.05 (0.76) CA-3 CA-2 vs 2.05 (0.83) CA-3
− 0.98, 2.24
.440
1.23, 4.91
.001
0.43, 4.45
.018
− 1.32, 1.32
–
0.54, 3.56
.008
0.40, 3.70
.016
drugs in 57 syringes and 139 ampules were collected from 166 cases, amounting for an average cost per case of $10.86 for discarded medications. The medications contributing to the greatest cost of waste were phenylephrine (21%), propofol (15%), vecuronium (12%), midazolam (11%), labetalol (9%), and ephedrine (9%) [4]. A separate study of 25 481 surgical patients calculated the percentage of drug actually administered to patients relative to the amount dispensed. Only 33% of succinylcholine prepared for patients was administered, and two-thirds of the prepared drug was wasted [7]. Similarly, 51% of propofol, 47% of midazolam, and 39% of rocuronium was prepared but not administered [7]. The most common reason for drug waste was need to dispose of full or partially full syringes. Pediatric anesthesiology data yielded similar results. Nava-Ocampo et al conducted a study concluding 80% of epinephrine, naloxone, flunitrazepam, ephedrine, and cisatracurium were wasted, with rocuronium and nalbuphine having the highest waste cost [8]. Medical waste is directly relevant to the practice of medicine, as it represents a misuse of resources that could otherwise be spent on patient care [5]. Operating rooms produce a disproportionately large percentage of total hospital waste. Much more can be done to better manage supply and drug waste resulting from surgical procedures [7-11]. The institution of training modules or lecture materials directed toward specific milestones may have a very positive impact on waste due to anesthesiology residents. Examples of such milestones are patient care 2: anesthetic plan and conduct; systems-based practice 1: coordination of patient care within the health care system; and practiced-based learning and improvement 2: analysis of practice to identify areas in need of improvement. Another very important issue frequently encountered among anesthesia providers is drug abuse. Despite substantial advances in our understanding of addiction and the technology and therapeutic approaches used to fight this
236 disease, addiction still remains a major issue in the anesthesia workplace, and outcomes have not appreciably changed [12]. Although alcoholism and other forms of impairment, such as addiction to other substances and mental illness, impact anesthesiologists at similar rates to other professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still an opioid [12]. Often, it is the individual who has this disorder who is the last to recognize the problem. It is, therefore, imperative that those people most likely to observe the signs and symptoms of addiction, that is, the relatives, friends, and coworkers, gain a clear understanding of the disease and understand what to do if they suspect someone may have a problem. Early identification of the affected individual can often prevent harm, both to the impaired physician and to his or her patients. Early detection is often difficult due to the compartmentalized relationships the individual may have with different members of their social structure. An important change that may be observed in an affected individual is consistently using an increasing amount of opioids or quantities inappropriate for a given case load [12]. We believe that the methodology of our study can be helpful in isolating such individuals and possibly helping in dealing with certain behaviors that we briefly touched upon. Gradual but consistent achievement of different milestones as residents progress through training is paramount. Some of the attributes are assessed objectively through standardized tests [1,3]. Learning and assessment of other attributes may not be as clear cut. Factors that help a resident decide which opioid to request and in what quantity at the start of a clinical day are numerous and involve the exercise of a complex intellectual process. Type of surgical procedure, comorbidities, patient history of opioid use, pharmacology of the drug, and plan for disposition are some of the factors that require consideration before decision regarding the amount of opioid that will be needed. We looked to see if level of training influenced residents in choosing opioids to avoid waste and improve efficiency of our pharmacy distribution system. This study may show that existing educational content within the program achieves the outcome. CA-3 residents would have greater exposure to the curriculum related to opioid diversion and abuse and cost-effective care. This may increase awareness and improve habits related to opioid utilization. The results of this study demonstrate a positive correlation between a resident's ability to predict how much opioid is needed and level of training. This report has inherent limitations due its retrospective design, and future study should use a prospective database. In addition, more representation existed
D. Roberman et al. from CA-1 vs CA-3 residents. This was due to the senior-level residents' involvement in longer and more complex cases. However, senior residents had statistically better ability to predict the absolute amounts of opioids to be used which, in fact, may be more difficult in complex patients. The CA-3 sample was not limited to few residents. A wide range of representation across the entire class existed. Furthermore, this is a preliminary report of our findings with a small sample size. Although our results have statistical significance, a large sample size will provide a better comparison of CA-1 to CA-3 patterns. A follow-up with an in-depth analysis will shed light on the dollar value of potential cost reduction as a result of modified dispensing protocols. In summary, our findings support the idea that residents are able to better predict their opioid requirements for cases as they progress through training. Closely monitoring such patterns can serve a useful educational purpose and allow for identification of misuse. Improvement in cost-effective care and limiting waste while working in a complex integrated health care environment are additional benefits.
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