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Saving
Costs and Enhancing Patient Care: Peter W. Chan, PharmD
With
the advent of global fees and decreasing reimbursement schedules,
outpatient surgicenters have had to scrutinize procedures and costs of
performing them. The
cost-cutting strategy is essential for the long-term success of
surgicenters. In intraocular lens procedures, for example, spending
approximately $50 per procedure on the irrigation solution is not
uncommon, using one of the premier products on the market. Typically, less than 150ml of the 500 mL bottle is used and
the remaining solution is discarded.
To cut costs, many practices are tempted to spike the bottle more
than once, or use the existing bottle and irrigation line for the next
patient, both considered dangerous practices that may result in infection. There appears to be a safe and economic alternative to these
cost-saving strategies. This
article will answer many questions asked by ophthalmic surgical nurses
regarding this alternative. The
Procedure The
recent advances instrumentation for cataract extraction by
phacoemulsification using irrigation and aspiration have facilitated safe
and reliable extracapsular lens extraction.
The intraocular irrigation solution is an integral part of the
successful procedure. A safe
and reliable irrigation solution such as balanced salt solution by various
manufacturers, or BSS Plus by Alcon Surgical, Inc. is usually employed. Many surgeons desire to use more physiologic solution with
less toxicity on the corneal endothelium. 1,2 In
vitrectomy procedures, surgery may take 1 to 3 hours.
Studies suggest that BSS Plus is a better intraocular irrigating
solution for maintenance of human corneal endothelium. 3
As a result of excellent clinical results, many surgeons have
shifted toward the use of BSS Plus as their routine intraocular irrigating
solution. The cost is
approximately $50 per 500 mL bottle.
Due to advanced surgical techniques, most procedures require less
than the full 500 mL in each bottle.
Many surgeons are using 100 mL to 150 mL per extracapsular cataract
procedure and are concerned about wasting the remaining solution in the
bottle. The
Multiple-Use Dispensing System The
use of a presterilized, disposable, multiple-use dispensing system is not
new to the nursing and pharmacy professions.
Hospital pharmacists have been using such systems when compounding
intravenous admixtures and hyperalimentation solutions.
Tens of thousands of IV solution bottles have been compounded over
the years in hospital pharmacies with efficacy and safety.
These systems enable the pharmacist to use a “single use” bulk
container of electrolytes (50% dextrose), or IV lipids.
Single-use containers do not contain preservatives and therefore
should only be spiked once to avoid possible contamination and coring of
the stopper port. Multiple-use
systems are also employed when compounding IV solutions and
IV hyperalimentation solutions for neonates and premature infants. Irrigating
solutions are similar to IV solutions because they do not contain
preservatives and, therefore should not be spiked more than once. Multiple-use
dispensing tubing set systems have also been used safely by
medical-surgical nurses in constant bladder irrigation when an infusion
pump is employed, thus eliminating removal of the catheter after
completion of each irrigation solution container.
Continuous abdominal peritoneal dialysis also uses multiple-use
tubing sets and adapters with great success.
When devices are not available for other situations, innovative
nurses would improvise their own hook-ups. The
Multi-Spike presterilized disposable device is a safe and cost-effective method of using the 500 mL irrigating solution for up to
three patients (Figure). Development
of the Multi-Spike (manufactured by Surgin Surgical Instrumentation, Inc.
of Tustin, California) resulted from listening to the needs of the
surgicenter. “Surgeons and
nurses wanted to use the rest of the solution in a safe and effective way
after the bottle was initially spiked or opened.” according to Armand
Maaskamp, President of Surgin, Inc. The
sterile packaged Multi-Spike has a single spike that is inserted into a
solution bottle, with three branches, each terminating with a sealed
stopper port. A clamp in each
branch is closed to isolate the port from the upper tubing section and
three solution bottle. At the
end of a cataract procedure, the active branch is clamped closed.
A new, sterile irrigation set is then spiked into another sterile
port for use on the next patient. It
is the multiple-use dispensing system that allows for the continuous
delivery of irrigation solution through three sterile ports after the
initial spiking of the ophthalmic irrigation solution bottle. According
to Surgin, Inc., with standard aseptic nursing techniques employed in using
Multi-Spike, more than 180,000 patient surgeries have used this device
without one case of cross-contamination reported.
In independent tests conducted on Multi-Spike, cross contamination
of the irrigation solution from one patient to a second or third patient
could not be demonstrated. 4 When
using the Multi-Spike, it is important to observe the following
guidelines:
Cost
Savings Medicare
reimbursement programs implemented by the Health Care Financing
Administration are under continuous scrutiny.
The most recent change in Medicare reimbursements for ambulatory
surgery centers became effective in early 1990.
This directly affects health-care facilities because approximately
80% of cataract procedures are reimbursed by Medicare. There
are actually two systems for reimbursement: one for hospitals and another
for ambulatory care facilities. Medicare
currently reimburses hospitals at a higher rate than ambulatory care
facilities. Over the next two
years, it is anticipated that the hospitals’ reimbursement fees will be
lowered to reflect fees similar to ambulatory care facilities. By
using the inexpensive Multi-Spike device ($18), the %40 bottle can be used
for three patients, resulting in savings of up to $30 per procedure, or
more than $40,000 per year for the average surgicenter.
The cost per patient is reduced approximately $23, as opposed to
$50. The Multi-Spike does not
compromise safety or change the volume of BSS Plus used per patient.
The cost savings results in more bottom line dollars that can be
applied towards other needs at the surgicenter or hospital without added
charges to the patient or attempts to increase reimbursements. Summary With the high cost of medical care, it is
satisfactory to find and use products that result in savings and, at the
same time, maintain quality patient care.
The temptation to spike a single-use irrigation bottle more than
once exists and occurs, a dangerous practice that may result in infection.
Multiple-use disposable systems have been used in other areas of
medical and pharmaceutical practice.
Multi-Spike allows ophthalmic surgeons to completely use one
irrigating solution bottle for up to three patients, use exact required
amounts of solution needed for the procedure, seal off the used port, and
discard the irrigation line after each patient.
Multi-Spike stops needless waste of expensive irrigation solutions
with safe and effective cost savings.
The resultant increased bottom line dollars for the surgicenter or
hospital could be used for other purposes.
Multi-Spike is the ophthalmic irrigation solutions’ solution. References 1.
Edelhauser HF, Van Horn DL, Hyndiuk RA, Schultz RO.
Intraocular
irrigating solutions: Their effect on the corneal endothelium. Arch Ophthalmol.
1974: 93:648-657. 2.
Edelhauser HF, Van Horn DL, Schultz
RO, Hyndiuk RA.
A comparative toxicity of intraocular irrigating solutions on the
corneal endothelium. Am J. Ophthalmol.
1976: 81:473-481. 3.
Edelhauser HF, Gonnering R, Van Horn DL.
Intraocular irrigating solutions.
Arch Ophthalmol. 1978:
96:516-520. 4. Multi-Spike FDA registration file, May 1986. Placentia, Calif.: Surgin Surgical Instrumentation, Inc. Test data: February 24, 1988. Address correspondence to Peter Chan, PharmD, Chan & Associates, PO Box 7398, Northridge, California 91327
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