The COVID-19 global pandemic required a change in practice for most areas of healthcare. A range of new challenges were presented for which solutions were required at very short notice. One of these issues was how to reduce waste in theatre, whilst complying with infection prevention regulations.
One of the areas in which waste could be reduced was the use of drugs in acute theatres. Joint guidance was released on 02/04/20 by the RCoA, AAGBI, FICM and ICS (1) outlining ways to change anaesthetic drug use and administration during the COVID pandemic. This guidance included a list of drugs which could be at risk of shortage due to their use as a priority drug on critical care units .
This guidance also highlighted six main ways in which drug wastage could be minimised. One of these points was to ‘Decrease waste: only draw up what you will use including emergency drugs’.
Common practice before COVID-19 would be to draw up emergency drugs at the beginning of the day and use only as needed, keeping those drugs not used between cases within a list. Increased infection prevention regulations in aerosol generating environments meant that it was no longer possible to keep drugs between cases unless in a sealed container, with all other equipment exposed to the AGP which could not be deep cleaned being disposed of.
To minimise waste of emergency anaesthetic drugs in obstetric and acute theatres in a teaching hospital during COVID-19.
This was an evolving project, based on clinical need and continual feedback from anaesthetists in obstetric and acute theatres.
Obstetric theatres already had a system of drug boxes for LSCS under spinal or general anaesthetic. A change in layout of theatres meant that two separate supplies of these drugs was required. The drugs in the boxes were rationalised and new plastic sealable drug boxes were made to provide for this need.
No such system for preparing emergency drugs was available in acute theatres as in obstetric theatres. The first iteration in acute theatres used a clear plastic ziplock bag, with emergency drugs drawn up inside and a card stating the date and time drawn up. It was felt that this bag was not secure enough and difficult to clean sufficiently.
The second design was to use a plastic sealable box. Stickers for the drugs required were placed on the front. The drugs were drawn up at the beginning of the day and were taken into acute theatres. The boxes were wiped down between cases and replaced if opened.
Informal feedback was collected from the anaesthetists working in acute theatres during the COVID-19 pandemic. Due to increased workload to all involved it was not practicable to measure change in in anaesthetic drug waste in any quantitative fashion.
Although not directly measured, I feel that the emergency drug boxes in theatres have meant a dramatic reduction in drug wastage when compared with drawing up emergency drugs for each case and discarding them when not used. Informal feedback from anaesthetists working in obstetric and acute theatres was positive and is discussed below.
This small change was one of many happening simultaneously at a time of increased stress and clinical pressure. All members of the team were learning to work in a new environment with new pressures.
The anaesthetists in our department took well to the use of drug boxes in theatres. Most felt comfortable to have the drugs readily available if needed. There was often a delay getting unexpected required equipment into theatres- if emergency drugs were left outside this would compromise patient safety.
Commonly for cases where use of drugs such as metaraminol could be expected to be required these were drawn up in addition to the emergency drug box. This meant the box could remain closed and only those drugs required were used. Some commented on a reduction in workload and mental load drawing up emergency drugs only once at the beginning of the day.
Some have commented that as we return to normal working in theatres they will continue to use the emergency drug boxes.
This project occurred at a time of change in many areas. Theatres were working at full capacity under challenging conditions. This meant that quantification of the effect of changes was not practical at that time and a more qualitative approach of taking informal colleagues was applied. This is a huge limitation to the project, but made it possible within the confines of our current working environment.
The simple introduction of emergency drug boxes in acute and obstetric theatres has been well accepted and is likely to have resulted in a reduction in waste of anaesthetic emergency drugs.
1 ICM anaesthesia COVID-19 (2020) Accessed online 10/04/2020: https://icmanaesthesiacovid-19.org/drug-demand-supply-anaesthetic-drug-usage-and-administration