Inhalers Waste in Hospitals: A Frustrating Dilemma

Timothy H. Self, PharmD
Sami A. Sakaan, PharmD, BCPS
Volume 56 - Issue 6 - June 2016

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and accounts for approximately 800,000 hospitalizations annually.1,2 Asthma affects 24 million Americans and results in roughly 500,000 hospitalizations each year.1,3 Hospitalized patients with COPD or asthma routinely have inhaled medications—metered-dose inhaler (MDI) or dry-powder inhaler (DPI)—ordered for acute and maintenance therapy.4,5

Hospitals often are faced with a frustrating dilemma: Should patients be allowed to take their multidose medications (eg, inhalers, insulin, eye drops, topical creams) home upon discharge? The natural inclination, of course, is to allow patients to take home medications that have been prescribed to them, because otherwise these medications—that have been paid for—will be discarded.

The problem is that to be released home with the patient, these products must be labeled appropriately in order to comply with state boards of pharmacy regulations. Consequently, strict adherence with these regulations dictates that inhalers should be discarded and not given to patients to take home (unless they have proper prescription labeling as if they were coming from an outpatient pharmacy). Unfortunately, many hospital pharmacies do not have adequate staff or time to provide such labeling at the time of discharge, which makes this a major economic and practical concern.

Extent of Inhalers Waste

To assess the amount of and the estimated cost of wasted doses of medications via MDI or DPI, a retrospective study recently was conducted at our institution in 478 hospitalized adult patients with a primary diagnosis of COPD/asthma. Of the total MDI or DPI doses dispensed, substantial waste of inhaled medications was found—87% of doses were wasted at an estimated hospital cost of $86,973.6

Among approximately 1.3 million hospital admissions for COPD and asthma each year in the United States, the economic waste associated with unused doses of medications via MDI and DPI is remarkable. For a very rough estimate of economic waste based on the results of our study, the average hospital cost of wasted inhaler doses alone per patient was $182; if similar waste occurs in other hospitals, the waste per patient multiplied by 1.3 million admissions for COPD/asthma annually would yield an estimated hospital waste in the United States of more than $236 million.6 To our knowledge, there have not been any other published studies assessing the amount or the cost of wasted inhalers.

While the cost of the waste is remarkable, the associated human suffering is even greater, especially as many of these patients are indigent. Dispensing partially used multidose inhalers at discharge ensures that the patients have a continued initial supply of medication and allows more time for patients to fill prescriptions after hospitalization.

Potential Strategies

Given the extent of the waste, economic burden, and suffering, several strategies have been implemented or have been suggested in the literature. Conzelmann and colleagues7 acknowledged this dilemma and proposed a practice of labeling MDIs and DPIs appropriately before patients are discharged from their hospital. In their health care system, a generic preprinted label was added to the patient barcode label. The label was put on a clear, resealable plastic bag, and the inhaler was placed in the bag.

Implementing a similar approach, Blee and colleagues8 conducted a 2-phase study to assess the effects on hospital readmission rates of dispensing inhalers to patients with COPD before discharge. The first phase (412 patients) involved the collection of clinical data for patients with COPD who had hospital orders for the study inhalers. The second phase (208 patients) included the collection of data for the time period after the multidose medication dispensing on discharge (MMDD) implementation. In this phase, pharmacists relabeled multidose inhalers used during hospitalization with appropriate outpatient labels, gave the patient the COPD-related multidose medications, and provided counseling for their appropriate use. The intervention was associated with a significant reduction in 30-day readmissions (P = .0016) and 60-day readmissions (P = .0056). The authors concluded that a targeted pharmacy program to provide COPD patients being discharged from the hospital with the multidose inhalers that they had used during hospitalization was associated with improved medication adherence, as measured by prescription filling behavior, and reduced rates of 30- and 60-day hospital readmissions.8

Other hospitals have used a common MDI canister approach by using a single MDI canister to administer medication to multiple patients. Advocates of this program cite cost savings, reduced treatment delays, and staff efficiency, but opponents maintain that such benefits are not outweighed by the small potential risk of cross-contamination if a decontamination protocol is not followed.9-15 The Institute for Safe Medication Practices commented on the common canister approach; however, no definite recommendations were given.16 Careful decontamination protocol development and strict adherence to the protocol were suggested.16

Another approach to resolving this problem includes the development of unit-dose institutional inhalers. However, at this time, only a limited number of unit-dose inhaler products are available on the market, and further assessment of the cost savings associated with this approach is warranted.

In summary, the extent of inhalers waste in hospitals is substantial and remains largely unaddressed among US hospitals. Further assessment of this problem is necessary, and practical and efficient strategies, such as relabeling multidose inhalers for patients to use upon discharge, are urgently needed to reduce wasted inhalers and improve outcomes.

Sami A. Sakaan, PharmD, BCPS, is an internal medicine clinical pharmacy specialist at Methodist University Hospital in Memphis, Tennessee.

Timothy H. Self, PharmD, is a professor of clinical pharmacy at the University of Tennessee Health Science Center and the program director of the Postgraduate Year 2 Internal Medicine Pharmacy Residency at Methodist University Hospital in Memphis, Tennessee.

References:

  1. American Lung Association. How serious is COPD. http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/learn-about-copd/how-serious-is-copd.html. Accessed May 31, 2016.
  2. Woods JA, Usery JB, Self TH, Finch CK. An evaluation of inhaled bronchodilator therapy in patients hospitalized for non-life-threatening COPD exacerbations. South Med J. 2011; 104(11):742-745.
  3. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120(5 suppl):S94-S138.
  4. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: Updated 2015. Brussels, Belgium: Global Initiative for Chronic Obstructive Lung Disease. 2016. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Accessed May 31, 2016.
  5. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127(1):335-371.
  6. Sakaan S, Ulrich D, Luo J, Finch CK, Self TH. Inhaler use in hospitalized patients with chronic obstructive pulmonary disease or asthma: assessment of wasted doses. Hosp Pharm. 2015; 50(5):386-390.
  7. Conzelmann J, Karyl K, Sarnicola S, Wierenga B. Preventing medication waste while promoting safe administration. Patient Safety and Quality Heathcare.  http://www.psqh.com/novemberdecember-2009/310-medwise. Published June 11, 2009. Accessed May 31, 2016.
  8. Blee J, Roux RK, Gautreaux S, Sherer JT, Garey KW. Dispensing inhalers to patients with chronic obstructive pulmonary disease on hospital discharge: effects on prescription filling and readmission. Am J Health Syst Pharm. 2015;72(14): 1204-1208.
  9. Filippelli A, Gregory G. Multiple patient metered dose inhaler (MDI) program. Abstract presented at: American Society of Health-System Pharmacists Midyear Meeting; December 9, 1997; Atlanta, GA.
  10. Hinson D, Rau JL. Incidence of contamination of metered dose inhaler canisters when used with multiple patients using spacer devices. Abstract presented at: American Society of Health-System Pharmacists Midyear Meeting; December 9, 1997; Atlanta, GA.
  11. Dunlevy CL, Rau JL, Roman SB. Surveillance of reservoir cross-contamination with multiple patient MDI use. Abstract presented at: American Association of Respiratory Care International Conference; December 1997; New Orleans, LA.
  12. Sheils SG, Duncan JL, Wojciechowski WV. The common canister protocol using the Monaghan AeroChamber reveals no cross-contamination and potential cost savings. Respir Care. 2000; 45:981.
  13. Wojciechowski WV, Maddox HC, Moseley AL. Analysis of cross-contamination of metered dose inhalers when using the Respironics Optichamber under the common canister protocol. Abstract presented at: American Association for Respiratory Care International Congress; 2004; New Orleans, LA.
  14. Siemens D, Petter S. Implementation of an oral inhaler therapeutic interchange and common canister program in a multi hospital health care system. Abstract presented at: American Society of Health-System Pharmacists Midyear Clinical Meeting; December 6, 2011; New Orleans, LA.
  15. Caselnova DA, Kuiper R, Neuman J. Implementation of a common canister protocol for selected metered dose inhalers in a community hospital. Abstract presented at: American Society of Health-System Pharmacists Midyear Clinical Meeting; December 8, 2009; Las Vegas, NV.
  16. Cohen MR, Smetzer JL. Shared metered dose inhalers: Is cross-contamination avoidable? Hosp Pharm. 2009;44(7):546-548.