Medical Supply Recovery Survey: A descriptive study of discarded, unused medical supplies in the UPMC health system

Jonathan Landry, M.S., MedStudent IV

University of Pittsburgh School of Medicine

For completion of an Area of Concentration in Global Health

Problem Significant amounts of unused medical supplies are disposed of in

hospitals, in excess over $200million/year*– This monetary figure is based on studies of OR discarded supplies.

To date, recovery in other areas of the hospital has not been analyzed**

Other studies have mentioned reasons for disposal of such supplies, but have never explicitly explored them, reasons passingly mentioned are:**– Expiration date, supplies opened in preparation for procedure that

was canceled, over-preparation in OR In our anecdotal experience, there are other reasons for disposal as

well as other significant sources of discarded supplies in hospitals. Since medical supply recovery is now hospital wide and the materials are even more heterogenous than simply OR materials (in many cases not requiring reprocessing), an analysis of such reasons is needed – We suspect other reasons such as pathogen contamination and warehouse

restocking issues, quantifying these reasons will help steer recovery efforts.

*Rosenblatt 1993, ** Rosenblatt 1992

Objectives

Which departments are most likely to have unused discarded supplies?– Does having the materials correlate with those

who are or are not recovering? What types of unused supplies are most

frequently discarded?– Does the type of material vary by department?

Why are these unused supplies are discarded?– Do the reasons for waste vary by department?

Materials & Methods

An online survey was distributed to employees of different departments in the UPMC health system– Employees were sent an invitation email with a link and

their participation was tracked A count and sorting of various unused medical

supplies was done at 5 sites in the hospital at which medical student volunteers currently collect– Items were coded by type, quantities, category, and

apparent reason for discarding

Sampling I Departments were defined based on an

organizational chart of the Shadyside and Presbyterian hospitals. These departments were extrapolated to the entire UPMC system

A general search for “nurse” was used, but in responses this was separated into ICU, Stepdown, General floor and Not Otherwise Specified, to account for different levels of care

Emails and names of employees from each department were obtained based on key word searches of the Employee database (e.g. Surgical services, maintenance or cardiology or nursing)

Sampling II Administrative, student/trainee and information

technology personnel were excluded. In each department, 30% of employees were

sampled (by job title), and depending on response, more were sampled until an overall response of 10% for that department was reached

In cases of small numbers of certian employees in a department (10 or less), all were sampled.

In the case of general nursing, 1 in 7 nurses of the first 2200 of 6000 nurses was sampled, due to time constraints.

Characteristics of the sample

Response Rate 7% (90/1287)

(Some sections of survey had a decreased response rate i.e.drop out, therefore “n” is not constant throughout survey)

Hospital Department

Employees sampled

Breakdown of respondents

23%

2%

24%

41%

10%

Clinical Tech

Clinician

Managers

Nurses

Non Clinical Tech

N=87

Clinical technicians: radiology techs, phlebotomists, nursing assistants

Nurses: BSN, RN, professsion staff nurse.

Clinicians: MDs and Nurse clinicians

Managers: HUCs, Nurse coordinators, Unit Directors, Pharmacy managers

Non-Clinical techs: Inventory technicians, histotechnicians,

Results 1) Have you ever recovered

unused medical supplies...?– Yes: 21.3%– No: 78.7% n=89

2) Does your department have unused medical supplies?– Yes: 57.1% – No: 42.9% n =84

Rates of recovery averaged less than 15% n=27

Department Number of “yes” responses to question 2

(number of respondants)

%

Cardiology 5(10) 50%

Central Supply 3(5) 60%

IV team 0(1) 0%

Emergency 5(7) 71%

Laboratory 1(4) 25%

Nursing Gen floor 4(4) 100%

Nursing Stepdown 2(2) 100%

Nursing ICU 15(19) 79%

Nursing NOS (e.g. Outpt)

1(5) 20%

Pharmacy 1(2) 50%

Radiology 5(9) 55%

Respiratory 2(9) 22%

Surgical Services 3(3) 100%

Transplant Svc 1(2) 50%

Rad Onc (other) 0(1) 0%

Types of unused medical supplies

Respondents: n=24, 77 non-distinct supplies enumerated by respondents

(By survey response, all departments)

29%

19%

8%6%

32%

1%

5%

Wound care

Vascular supplies

Gen Disp Surgical

Respiratorysupplies General pt caresupplies Specialist/kits

Meds by class

Types of unused medical supplies(By Physical Count)

Number & Types of Medical Supplies vs. Collection Site

0

10

20

30

40

50

60

70

80

ICU CentralSupply I

CentralSupply II

Stepdow nUnit

OR

Collection sites

Nu

mb

er

of

ite

ms

personal

respiratory

specialist/kits

surgical

vascular

w oundcare

general

(878) (219) (267) (168) (230)

(Absolute quantity of items)

Reasons for disposal of unused supplies

not impt little impt somewhat impt very impt avr response % of response score (ave x %)

Expiration date 0% (0) 7% (1) 21% (3) 71% (10) 3.64 50%(14) 1.82Pathogen contamination (materials in isolation rooms) 0% (0) 9% (1) 36% (4) 55% (6) 3.45 39%(11) 1.35

General contamination (dropped on floor, etc). 14% (1) 0% (0) 29% (2) 57% (4) 3.29 25%(9) 0.82Procedure/ order change 0% (0) 17% (1) 50% (3) 33% (2) 3.17 21%(6) 0.69Change in model purchasing 33% (3) 33% (3) 33% (3) 0% (0) 2 32%(11) 0.64Difficulty restocking 55% (6) 36% (4) 9% (1) 0% (0) 1.55 39%(11) 0.60Quality Control 0% (0) 50% (4) 25% (2) 25% (2) 2.75 21%(10) 0.58Obsolete/ incompatible item 20% (1) 20% (1) 40% (2) 20% (1) 2.6 17%(5) 0.46Physician preference change 33% (2) 17% (1) 50% (3) 0% (0) 2.17 17%(6) 0.38Other 0% (0) 0% (0) 50% (1) 50% (1) 3.5 7%(2) 0.25

“()” indicates # of respondents total respondants 28

Question: “Please rate the reasons why you might dispose of unused medical supplies.”

•“Response average” was weighted by the percent who responded to the particular category to create the “Score” in the right hand column

• Because of the decreased response from individual departments only the aggregate data is shown

x =

x =

x =

x =x =

x =

x =

x =x =

x =

Barriers to supply recovery

Not Important

A Little Important

Somewhat important

Very Important

Response Average

% Total Respondents

Score (response Avr x %) 

Knowledge of what to recover 5% (3) 11% (7) 33% (20) 51% (31) 3.3 100% (61) 3.3

Someone to pick up recovered materials 4% (2) 12% (7) 32% (18) 53% (30) 3.33 93%(57) 3.11

Space to put the recovered materials 7% (4) 12% (7) 37% (22) 44% (26) 3.19 96%(59) 3.1

A person to contact about questions 3% (2) 17% (10) 38% (22) 41% (24) 3.17 95%(58) 3.0

A container to put the items in 10% (6) 22% (13) 28% (17) 40% (24) 2.98 98%(60) 2.9

Time to collect the supplies 9% (5) 18% (10) 37% (21) 37% (21) 3.02 93%(57) 2.8

Other 40% (4) 0% (0) 20% (2) 40% (4) 2.6 16%(12) 0.4

“()” indicates # of respondents Total Respondents   61    

 

x =

x =

x =

x =

x =

x =

x =

“Response average” was weighted by the percent who responded to the particular category to create the “Score” in the right hand column

“Assuming you had supplies to recover, what would limit the collection of medical supplies for you?”

Discussion I There are multiple sources of bias within the study:

– The method of sampling using the employee database may leave out some departments in the hospital and even some hospitals. The employee database was not seachable to specify multiple variables. Age and sex were not controlled for because they were not deemed important variables in the analysis

– The methodology of an internet-based survey allows ease of response however • There were rates of 50%-100% email bounceback rates in some departments,

indicating that employees had left or that they did not have emails. • Employees who do not have email are obviously excluded (linen, maintenance) and

will need followup via personal interview and/or phone

– Invitation emails were personalized to urge specific departments to respond and therefore respresent a form of bias

Sampling could be improved by :– Targeting employees in departments and hospitals which are

underrepresented– The survey should be performed in person and/or via phone, in

predefined locations and departments. The drop off in answering questions represents a design flaw in the survey

and may affect internal validity of the results– Improve of some survey questions by decreasing open ended questions,

reduce redundancy and follow up with respondents, may correct some of this bias

Discussion II The survey method itself is inherently limited by:

– Self-selection bias (those who are more interested in the survey are probably more likely to recover supplies)

– Self-estimation is very inaccurate, and open ended questions are even moreso (compared to the actual count of items)

There is overrepresentation (sampling bias) of some departments (e.g. ICUs, emergency) in sites already targetted by Global Links for recovery, so their rates of recovery are probably higher than others

Physical counts of collection sites need to be resampled to account for monthly variation

– Employees at specific collection locations could be surveyed intensively to correlate the reasons for disposal and the actual supplies

– Weight of supplies and cost data per item, will be obtained to extrapolate cost to the hospital– Collection sites themselves are biased because employees in a sporadic manner, it selects

against non-disposable items In Global Links´warehouse there is recovery of a significant amount of surgical

equipment, which is not reflected in the survey NOR in the medical student collection. – Medical student collections only represent about 1/10th of total amounts recovered from UPMC.

This indicates that our collection sites may not be respresentative of the entire hospital (sampling bias)

Conclusion I A majority (57%) of hospital workers surveyed have medical supplies

which they are not recovering There are likely differences in departments´ employees chance of

having unused supplies (p-value generation in process)– further sampling is needed in those departments where there were

not enough respondents Expiration date, contamination (general and pathogen) and procedure

changes are among the main reasons for discarded supplies (p-values in process)– Because there is theoretical pathogen contamination of certain

ICUs supplies, we have instructed staff to not collect such theoretically exposed supplies

Types of supplies vary by collection site – Certain collection sites have high value specialty items which may

be worth higher scrutiny (e.g. ORs and Central Supply)– Collection of discarded supplies can be tailored to the type of

material (some materials are inherently unsterile or not likely to have an expiration date, e.g. O2 masks)

Conclusion II Knowledge, time, space for supplies, person to contact were very

important barriers to recovering unused supplies – This indicates areas of outreach to address for GL

ICUs and Central Supply areas represent sources of unused medical supplies both in terms of diversity of items and numbers of supplies

Suggestions for study:– Follow up study for pathogen contamination study of unused medical

supplies as fomites to determine level of risk of recovery– Investigate which materials are high value and if other methods of recovery

are practicable (e.g. resterilization)– Alter ICU practices to decrease the amount of waste

Immediate practical applications:– Recovery can be rationally targetted towards the most likely high yield

departments (OR, Central Supply, ICUs, Step-down units, Radiology) – New areas such as Pharmacy, should be explored – A web-based inventory tracking system would be the next step to more accurately

track materials which are collected from all sites

References & Acknowledgements References

– Czajkoski-Beckwith, Helen, Rosenblatt, WH. “Reprocessing unused surgical supplies for use in developing countries” AORN. 63(1).1996 p 236

– Rosenblatt, Silverman, “Cost-Effective use of operating room supplies based on the Remedy database of recovered unused materials,” Journal of Clinical Anesthesia, 400

– Rosenblatt “Case-by-Case Assessment of recoveryable materials for overseas donation from 1318 surgical procedures” JAMA 1993 269. 2647-2649

– Rosenblatt WH, Silverman DG “Recovery, resterilization and donation of unused surgical supplies” JAMA 268 1441-1443

Acknowledgement and thanks

– David Paterson, MD, Diane Pakstis, RN,

– William Markle, MD, Joan Harvey, MD

– Global Links, the non profit partner organization

– Employees who participated in the survey

– Employees and medical students who collect supplies

Partner organization Global Links (GL), a non-profit organization,

receives unused medical supplies from many hospitals. GL organizes, quality-assures and packages medical supplies for developing countries. These supplies play a critical role in the functioning of many hospitals globally.– GL rely on volunteers within hospitals, and does

careful inspections of all materials,• It is not known why these materials were recovered or

necessarily which employees discard these materials