BACKGROUND   Pressurized metered-dose inhalers (pMDIs) are commonly used for

aerosolized medication delivery in mechanically ventilated patients because standard nebulizers add flow to the ventilator circuit and increase the risk of circuit contamination

  Costs for Combivent® pMDI (ipratropium/albuterol) have substantially increased and Combivent® will be removed from the market in late 2013 due to CFC propellant phase-outs

  Vibrating mesh nebulization (VMN) is newer technology that allows for more efficient aerosol drug delivery, utilization of unit-dosed medications, adds no flow to ventilator circuits, and is protected from contamination via a physical barrier between the aerosol pathway and medication reservoir

RESULTS DISCUSSION   Potential advantages to using VMN over pMDI –  Higher percentage of respirable drug available for deposition in the lung –  Physical barrier between the aerosol pathway and medication reservoir,

potentially leading to infection reduction –  Limits variability in administration technique and dose delivered –  Utilization of single-use, unit-dose medications –  Eliminates bedside storage/security and infection control concerns with pMDIs

  Since the conversion from pMDI to VMN administered medications occurred on an institution-wide basis, retrospective review of aggregate objective data were also done on an institution-wide basis –  Theoretic improvement in objective outcomes needs further prospective, patient-

specific data review, however our results confirmed that conversion did not negatively affect patient outcomes

  Subjective assessment of patients’ clinical response to medication administration via pMDI or VMN was conducted utilizing a survey format –  Ideally, data should be assessed on an objective basis using patient-specific

data. However, collecting objective data pre- and post-medication administration (i.e., PEEP, PIP, HR, RR, etc.) is not standard practice at our institution and this conversion was not undertaken to scientifically compare clinical efficacy of two administration techniques.

–  While survey-based research is subjective and at risk for recall bias, findings did reveal that care providers felt patients responded more favorably when medications were administered via VMN. Results also pointed towards patients experiencing more medication side effects with VMN administration. Both these results may be attributable to a higher percentage of respirable drug available for deposition in the lung.

  Cost assessments were based primarily on medication utilization of ipratropium/albuterol (Combivent® pMDI, DuoNeb®) –  One-time capital budget monies were provided by the Pharmacy Department to

the Respiratory Department for purchase of VMN equipment, enabling institution-wide conversion based on significant projected cost savings

CONCLUSIONS   This study illustrates a successful cost containment project achieved

through collaborative interdisciplinary efforts

  Converting from pMDI to VMN administered medications in mechanically ventilated patients resulted in significant medication cost reduction with no observed changes in clinical outcomes or end-user satisfaction.

  When making formulary decisions or therapeutic substitutions based on cost assessments, it is important to ensure patient outcomes are maintained

Conversion of Pressurized Metered-Dose Inhaler to Vibrating Mesh Nebulizer Administered Medications Cara McDaniel, PharmD, BCPS1; Brian Glynn, RRT1; Steven Gudowski, RRT1; Tiffany Pezzano, RRT1; Sandra Weibel, MD2 1Thomas Jefferson University Hospital, Philadelphia, PA; 2Thomas Jefferson University, Philadelphia, PA

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OBJECTIVES Institution-wide conversion from pMDI to VMN administered medications in mechanically ventilated patients was initiated in April 2011 as an interdisciplinary cost-containment project, but we needed to ensure patient care and outcomes were not adversely affected

This study was conducted to assess the following: –  Conversion from pMDI to VMN administered medications did not negatively impact

patient care –  Conversion from pMDI to VMN administered medications did not negatively impact

workflow or ease of medication administration –  Conversion from pMDI to VMN administered medications resulted in a net cost

savings

METHODS   Retrospective, IRB exempt review of financial performance, patient

outcomes, and end user satisfaction of new technology

  Study Dates: pMDI period April 1, 2011 – March 31, 2012 VMN period April 1, 2012 – March 31, 2013

  Study Design Part 1 Retrospective assessment of objective aggregate data collected for performance improvement and assessment activities Part 2 Anonymous, voluntary, cross-sectional survey of all Respiratory Therapists

Subjective data assessment of patient outcomes and end user product assessment

Part 3 Financial analysis of pre and post conversion period medication costs, focusing on ipratropium/albuterol (Combivent® pMDI, DuoNeb® inhalation solution)

  Data Analysis Student’s t-test for continuous data Mann-Whitney U test for ordinal data

0

1

2

3

4

5

6

7

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Day

s

Avg Ventilator Days

0

0.5

1

1.5

2

2.5

3

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Avg VAP Rate

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Day

s

ICU LOS

  No significant differences observed in average ventilator days, intensive care unit (ICU) length of stay (LOS), or ventilator associated pneumonia (VAP) rates

P = 0.434 P = 0.738

P = 0.784

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

Apr

-15

May

-15

Jun-

15

Jul-1

5

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Combivent® and DuoNeb® Spend by Month Combivent

Duonebs

AVERAGE PRE CONVERSION

  Medication costs were $310,678 and $101,850 in the pMDI and VMN periods, respectively

  Net cost savings observed: $208,828

pMDI to VMN Conversion

VMN set-up (Aerogen Solo® with Aeroneb® Pro-X controller)

pMDI set-up (Airlife™ MDI Adaptor)

  VMN felt to result in quicker improvement of respiratory status and indicators, easier to use in terms of administrative technique and infection control procedures, and results in less medication wastage

a pMDI

a VMN

No difference

I believe I waste more medication when I use:

True

False

  Dhand R. Aerosol delivery during mechanical ventilation: from basic techniques to new devices. J Aerosol Med Pulm Drug Deliv 2008;21(1):45-60.

  Ari A, Atalay OT, Harwood R, et al. Influence of nebulizer type, position, and bias flow on aerosol delivery in simulated pediatric and adult lung models during mechanical ventilation. Respir Care 2010;55(7):845-51.

  Emberger JS, Brown JM, Killian L. Cost reduction using Aeroneb Solo in a medical ICU ventilator population. Poster session presented at: the 57th International Respiratory Convention & Exhibition of the American Association of Respiratory Care; 2011 Nov 5-8; Tampa, Florida.

  Aeroneb® Solo Product Datasheet. Aerogen Ltd, Galway, Ireland. 2001. [PM086]

Cara McDaniel, Steven Gudowski, Tiffany Pezzano, and Sandra Weibel have nothing to disclose concerning possible financial or personal relationships. Brian Glynn serves as a consultant for Aerogen Ltd.