Correspondence
As in Gupta and Cook’s report [3], a contributory factor in our incidents was the potential for the net-sided pressure bag (type 1, above) to obscure the labelling and contents of the infusate. Clear pressure infusor cuffs (type 2) should have been the chosen option in our response, but we found a significant issue with both types listed: neither cuff is manufactured to fit the Viaflo fluid bags we use as standard (Baxter, Deerfield, IL, USA), resulting in herniation of the bag or cuff failure. Unfortunately, this only became evident when these infusor cuffs were introduced into practice. We opted for clear-sided pressure infusor cuffs (type 3). These are of low cost, re-usable (unless soiled) and provide an unhindered view of the labelling and contents of the entire infusate, albeit on one side only. They also seem to be manufactured to fit all available types of fluid bag. In conclusion, we insist that all fluid pressurising devices should at least have a fully transparent front panel [4] and must be checked for the compatibility with the fluid bags used.
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References 1. Smith A. Lest we forget: learning and remembering in clinical practice. Anaesthesia 2013; 68: 1099–103. 2. Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia 2013; 68: 1114–9. 3. Gupta KJ, Cook TM. Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis. Anaesthesia 2013; 68: 1179–87. 4. Association of Anaesthetists of Great Britain & Ireland. Arterial line blood sampling: preventing hypoglycaemic brain injury. Anaesthesia 2014 6 Feb: doi 10.1111/anae.12536. 5. National Patient Safety Agency. Infusions and sampling from arterial lines. Rapid Response Report, 2008. http:// www.nrls.npsa.nhs.uk/resources/?entry id45=59891 (accessed 20/12/2013). doi:10.1111/anae.12671
Reducing the cost of anaesthesia Drug costs associated with anaesthesia can be reduced by supplying information about drug costs [1]. However, price lists may not be effective when they are long, show unit prices instead of cost-per-hour, or involve essential drugs with no low-cost alternative [2]. With ethical approval, we investigated whether any annual cost savings occurred when a costper-hour/cheaper alternatives sticker (Fig. 8) was placed on to anaesthetic vaporisers. To study the effect of the stickers, the quantities and monthly costs of agents delivered
M. Thirugnanam J. French Nottingham University Hospitals City Campus Nottingham, UK Email:
[email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
Figure 8 Cost sticker, attached to anaesthesia vaporiser.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
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Table 2 Quantity and costs of anaesthetic agents during the study periods in 2010 and 2011. 2010
Sevoflurane; l Isoflurane; l Remifentanil; g Propofol; g Fentanyl; mg Sufentanil; mg Total
2011
Relative change
Quantity
Cost; x 1000
Quantity
Cost; x 1000
Quantity
Cost
273 11 3 3065 872 335
€154 €1 €20 €16 €1 €5 €198
200 48 2 3063 631 414
€115 €5 €7 €17 €1 €6 €151
27% 332% 36% 0% 28% 24%
26% 327% 66% 6% 29% 24%
by our hospital pharmacy were compared between the first nine months (pre-sticker) of 2010 and the first nine months (post-sticker) of 2011, for all patients administered general anaesthesia, except those undergoing cardiothoracic and day-case procedures. No information or training was provided for anaesthetists between the two phases of the study. Total costs were calculated from the hospital pharmacy financial registry, which took into account price variation over time and price differential according to unit size. The quantities, total cost and percentage change in both of these parameters for each of the anaesthetic agents are shown in Table 2. There were no significant differences in the number of surgical procedures performed or prevalence of the type of anaesthesia (general, regional, with/ without supplemental nerve block) used during each time period (data not shown). The introduction of vaporiser price stickers saved the annual equivalent of ~5% from our
(£113; $188) (£1; $1) (£15; $25) (£12; $20) (£1; $2) (£4; $6) (£145; $241)
hospital’s anaesthesia drug budget (~€1.26 million (£0.92 million, $1.54 million) resulting from the increased use of low-cost alternatives. This saving is in line with the 0–48% previously reported [2, 3]. We suggest that our use of price-per-hour values on prominently located stickers served as a constant reminder to anaesthetists to administer cheaper alternatives. In comparison with other cost-cutting interventions, such as an education programme [4], feedback to individual anaesthetists about their costs [5] and guideline implementation [6], the use of stickers is cheap and safe, and we recommend their use to other anaesthetists interested in cutting the cost of anaesthesia delivery without adversely affecting patient care. M. J. L. Bucx J. J. Landman H. A. W. van Onzenoort M. Kox G. J. Scheffer Radboud University Medical Centre Nijmegen, The Netherlands Email:
[email protected]
(£84; $140) (£3; $6) (£5; $8) (£13; $21) (£1; $1) (£5; $7) (£110; $184)
No external funding and no competing interests declared. The authors are grateful to Berti Moonen and Joris Kleinhans for interrogating the anaesthesia databases.
References 1. Hawkes C, Miller D, Martineau R, Hull K, Hopkins H, Tierney M. Evaluation of cost minimization strategies of anaesthetic drugs in a tertiary care hospital. Canadian Journal of Anesthesia 1994; 41: 894–901. 2. Horrow JC, Rosenberg H. Price stickers do not alter drug usage. Canadian Journal of Anesthesia 1994; 41: 1047–52. 3. Kirsch MA, Carrithers JA, Hagan RH, Borra HM. Effects of a low – cost protocol on outcome and cost in a group practice setting. Journal of Clinical Anesthesia 1998; 10: 416–24. 4. Johnstone RE, Jozefczyk KG. Cost of anesthetic drugs: experiences with a cost education trial. Anesthesia and Analgesia 1994; 78: 766–71. 5. Body SC, Fanikos J, DePeiro D, Philip JH, Segal BS. Individualized feedback of volatile agent use reduces fresh gas flow rate, but fails to favorably affect agent choice. Anesthesiology 1999; 90: 1171–5. 6. Lubarsky DA, Glass PS, Ginsberg B, et al. The successful implementation of pharmaceutical practice guidelines: analysis of associated outcomes and cost savings. Anesthesiology 1997; 86: 1145–60. doi:10.1111/anae.12687
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