Implementation of optimized epidurals in the anesthesiology pain service at UNC Medical Center: A pilot study

A previous project was completed to evaluate the opportunity to standardize and optimize epidural use at the UNC Medical Center. VERB (vial, exchange, rate, and bag) analysis was applied to identify preparations optimized for efficient supply and resource utilization. Converting a hydromorphone/bupivacaine epidural preparation from a total bag volume of 250 mL to 100 mL was proposed for a pilot study. The primary objective of this implementation study was to assess the operational impacts on drug and fluid utilization and waste.

A quasi-experimental, single-center pilot implementation study was conducted at a large academic medical center. The proposed volume change was piloted in 2 units for a duration of 6 months. Data from various sources were collected, including administration data documented in the electronic health record and epidural infusion pumps and dispense and waste data from automated dispensing cabinets. Outcomes assessed included the total drug volume infused, the total waste accumulated per encounter, the number of nursing bag exchanges per encounter, and nursing and pharmacy staff satisfaction.

Implementation of the 100-mL hydromorphone/bupivacaine epidural preparation resulted in a notable decrease in waste during the compounding and administration process. Nursing bag exchanges occurred at a higher rate than hypothesized per 48-hour period. Storing the epidural medication on the units allowed for timely administration and bag exchanges.

Storing epidurals at the site of care in automated dispensing cabinets increased nursing satisfaction, but the increased rate of bag exchanges remained a concern. Estimated decreases in drug and fluid waste should be noted for future hospital-wide implementation.