James Russell, RN-BC, Value Analysis Facilitator, VCU Health System, Richmond, VA
A robust Value Analysis department will collaborate with many other divisions within a hospital on a routine basis. These can include, but are certainly not limited to: Supply Chain, Pharmacy, Laboratory, Infection Control/Epidemiology, Performance Improvement/Quality, Patient Safety, Risk Management, Decision Support, Information Technology, and of course, Medicine and Nursing Leadership.
In a very real-world scenario, a hospital’s suppliers experience a shortage of intravenous (IV) fluids, specifically 1 liter bags of normal saline (NS). This shortage in supply will affect numerous clinical areas that utilize this product and will require a collaborative effort in strategizing ways to deal with it. Here are some examples of how Value Analysis can work with other departments to facilitate a project:
This is the entry point for IV fluids. Whether the facility classifies IV fluids as a drug (technically correct) or a supply, the Supply Chain department will usually be involved in the ordering (Purchasing), sourcing (Contracting), delivery (Central Receiving), and distribution (Central Supply) of the items.
Clinical departments that utilize the items will look to Supply Chain to keep them stocked of this necessary, and often life-saving, product.
A simple, yet often overlooked, driver of utilization can be individual nursing unit par levels. Central Supply can run a report showing the actual volume of the supply being used in each location. Perhaps one nursing area has a par level of 10 bags and they use an average of 3 per day. Their shelf stock is about 3 days’ worth. Perhaps another nursing unit has a par level of 20 bags and uses an average of 4 per day. Perhaps this second unit is a bit more vocal in its demands that “they never run out!” Since that second unit maintains a 5-day supply on their shelf, cutting it to a 3-day supply (12 bags) might be practical, as long as they never run out! Multiply this by 50 different locations and by trimming par levels to more realistic levels, CS could wind up “saving” many dozens of bags per day that can be used to combat the shortage (for a time).
These are the primary users of IV fluids. In a typical hospital, nurses will use liter bags of NS hundreds of times per day. This can equate to hundreds of thousands of “eaches” annually. Any alteration in utilization can have a dramatic effect. Consider the concept of “Keeping a Vein Open” (KVO). In many areas, where a patient has an IV catheter placed but no maintenance or primary IV fluids infusing, nurses will hang a bag at a very low rate (i.e. 10 ml/hour) to keep the vein from closing off. In this example, 10 ml/hour results in 240 ml per day. Most hospitals will have a policy requiring these bags of fluids to be changed every 24 hours. If the rate of the infusion never needs to go over 10 ml/hr, the facility could benefit from a practice change of encouraging the nurses to hang a 500 ml bag, or even 250 ml, instead of the 1 liter bag that is in short supply. In one facility, this practice alone accounted for a decrease in utilization of 1 liter bags of NS by 60-80 “eaches” per day.
Another area in which the department of nursing can be helpful with the IV shortage is Trauma. In one hospital’s busy trauma center, they hung (spiked the tubing into the bag) 1 liter bags of NS on their rapid infusers in anticipation of a trauma patient arriving. The hospital’s policy was to discard opened IV bags after 24 hours. This unit had 5 rapid infusers. By encouraging them to hang (but not spike) a bag of NS and tubing on the rapid infuser, this saved several bags of waste per day. It did, however, require them to remember to prime the tubing when they were alerted that a trauma patient was en route. The unit’s willingness to do this was an important collaborative step in helping the hospital as a whole.
When physicians are presented with the data concerning a project, they will often come up with their own solutions that can be quite effective. In one facility, the physicians agreed there were other IV solutions that could be just as effective as 1 liter bags of NS and agreed to have a pop-up alert in the electronic medical record come up whenever they ordered the solution that was in short supply. They had already put this practice in place with pharmaceuticals that were short. For example, if an MD placed an order for Midazolam and it was on the pharmacy’s drug shortage list, a pop-up window would alert the doctor and suggest an alternative drug. This is exactly what happened with the IV fluids. If the MD decided to order the 1 liter bag of NS anyway, they were required to document a rationale. This practice decreased the usage of 1 liter bags of NS by another 60–80 “eaches” per day.
When presented with the prospect of the hospital having to decrease its usage of 1 liter bags of NS, the Anesthesia department volunteered to prime their machines using other fluids. It was their habit to use 1 liter bags of NS, dozens of times per day, just to prime their anesthesia machines. Their willingness to contribute to decreasing utilization was very helpful.
By implementing the utilization techniques above, the facility was able to decrease its usage of the 1 liter bag of NS from 500 per day to 300. A 40% decrease in utilization. This is huge in terms of collaboration and teamwork. Broadcasting this interdepartmental coordination (sharing the credit) can go a very long way in encouraging future collaborations. Celebrating successes like this can lead to even greater ones down the road.
The common denominator in the IV fluid project is value analysis. VA team members can meet with clinicians and work through strategies that are realistic and based on data, without compromising safe and effective patient care. This works to the benefit of all concerned. Value analysis can make appropriate suggestions to clinicians about altering their practice without creating a hostile environment where clinicians and supply chain don’t listen to each other. By speaking both the language of operations (supply chain) and clinical (nursing/medicine), the Value Analysis Facilitator can lead the project toward a very impactful outcome.