Critical analysis of common canister programs: a review of cross-functional considerations and health system economics

Abstract

Respiratory inhalers constitute a large percentage of hospital pharmacy expenditures. Metered-dose inhaler (MDI) canisters usually contain enough medication to last 2 to 4 weeks, while the average hospital stay for acute hospitalizations of respiratory illnesses is only 4-5 days. Hospital pharmacies are often unable to operationalize relabeling of inhalers at discharge to meet regulatory requirements. This dilemma produces drug wastage. The common canister (CC) approach is a method some hospitals implemented in an effort to minimize the costs associated with this issue. The CC program uses a shared inhaler, an individual one-way valve holding chamber, and a cleaning protocol. This approach has been the subject of considerable controversy. Proponents of the CC approach reported considerable cost savings to their institutions. Opponents of the CC approach are not convinced the benefits outweigh even a minimal risk of cross-contamination since adherence to protocols for hand washing and disinfection of the MDI device cannot be guaranteed to be 100% (pathogens from contaminated devices can enter the respiratory tract through inhalation). Other cost containment strategies, such as unit dose nebulizers, may be useful to realize similar reductions in pharmacy drug costs while minimizing the risks of nosocomial infections and their associated medical costs. The CC strategy may be appropriate for some hospital pharmacies that face budget constraints, but a full evaluation of the risks, benefits, and potential costs should guide those who make hospital policy decisions.

Economic impact and chronic obstructive pulmonary disease outcomes of a comprehensive inhaler to nebulization therapy protocol implementation in a large multi-state healthcare system

“…A more recent assessment by another health system reported 90% of doses remaining unused, which correlated with the average LOS 6 . Our own internal evaluation of inhaler waste which was previously reported suggested a similar level of wasted doses (89%) and supports these assessments 7 . We additionally evaluated potential tiotropium (Spiriva Handihaler) waste more specifically since annual system costs exceeded $500,000 for this inhaler alone.…”

“…This was also successful in significantly reducing the number of inhalers stocked on formulary; however, lost inhalers and wasted doses were still very prevalent as stated previously despite being able to increasingly utilize the institutional size inhalers provided by GSK. Another option that many hospitals have entertained to curb inhaler costs and minimize waste is by instituting common canister (CC) protocols and although these can be successful they do require close attention to detail as it relates to infection control issues as well as associated processes to be sure certain patient populations are excluded 7 . Despite implementing the system-approved preferred inhaler therapeutic interchange in 2012, three urban community hospitals in our health system still found inhaler costs and waste to be unacceptable.…”

“…Secondary to the perceived success of the common canister implementations, the team initially recommended considering this for all campuses in the system with estimated drug savings of $833,000. However, due to the concerns with infection control risks accompanying this method of drug delivery, the system pulmonary and infectious disease clinical consensus groups (CCGs) would not support approval as a system standard 7 . As a result, the interdisciplinary team evaluated the alternative option of implementing an inhaler to nebulization protocol.…”

Use of a Shared Canister Protocol for the Delivery of Metered-Dose Inhalers in Mechanically Ventilated Subjects

“…However, further studies are required to determine the overall safety of shared canister therapy during mechanical ventilation, especially in other patient populations (eg, immune suppressed individuals) and non-ICU settings. 33 In this era of increasing antimicrobial resistance, an alternative approach would be to have smaller dose single-patient MDIs for hospital use.…”

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

“…There is weak evidence that the common canister protocol practiced in some hospitals can lead to cross-contamination. [ 209 ] In contrast, a recent study revealed that common canister protocol resulted in significant cost savings with similar rates of ventilator-associated pneumonia, mortality, as well as hospital length of stay, compared to single-patient pMDI. [ 210 ] Accordingly, each hospital should evaluate the risk–benefit ratio before following a common canister protocol.…”