Common Canister Policy Concerns
Respiratory directors and hospital administrators across the country are constantly on the prowl for new ways to save money or increase revenue. One gold mine taking the country by storm is the practice known as "common canister". For those of you not familiar with it, allow me to explain.
In a nutshell, the practice goes like this: Patient John Doe arrives in the emergency room. Upon admit to the floors, the physician has ordered Duoneb Q6 hours. The patient does not take nebulizers at home. Upon initial assessment by the RRT, it is determined that the patient is capable of doing a 5 second inspiratory hold. Therefore, the patient ("per protocol") is converted automatically to Combivent MDI Q6. Unless the patient is in isolation, they do not receive their own MDI. A "common canister" is loaded into the drawer of the Pyxis. Each patient is given their own spacer that is kept at the bedside. When doing rounds, the RRT goes to the Pyxis and removes the canister and charges the prescribed number of puffs to the patient. The canister is cleaned with an alcohol swab and then the same canister is used for the other patients on the floor who also have been automatically converted to MDI as opposed to the physician-ordered nebulizer.
Assuming a MDI holds 200 puffs (and thus charging $30-$50 per puff to many patients), this results in added revenue to the bottom line. Also, assuming that it takes much less time to administer the MDI than a nebulizer, hospitals can theoretically save money on FTEs. While this is not the case for smaller hospitals, larger hospitals can in fact work with fewer staff if the policy is to convert almost everyone to the more profitable MDI that you can charge 10 or 20 patients for as opposed to the single dose nebulizer that you can only charge one patient for.
(When I first heard about this, I was seriously waiting for the punch line because I was confident that it was some kind of joke.)
Now, hospitals will be very fast to point out that the practice is safe and legal if it is done correctly. (And they would be correct.) However, a few things that I think hospitals are quick to not factor into the equation are:
1) The fact of the matter is, hospital staff are not as compliant as we would like to think they are when it comes to infection control. Also, just wiping with an alcohol swab is not enough. You actually have to wipe it and then let it air dry before you recap it since it is the exposure time to the alcohol and the evaporation time that kills organisms. So, if study after study shows that staff do not even wash their hands at a good compliant rate, realistically what hope is there that staff will clean these MDIs at a compliant rate?
2) Hospitals will be fast to tell you that "studies show" that the risk of infection is low. While this is technically true, I would respectfully respond by saying that a) only about three studies exist on the issue and all of them are of very small number of patients (one of them was only 48 patients). So, it is hardly fair to claim that the jury is in on this issue when in fact there are no large studies on the issue yet.
3) Also, something else that is not being factored in is the hospital readmission rate. If John Doe was to be given his OWN MDI upon admit (that then got labeled and sent home with him at discharge) then he has a lower chance of being readmitted for the same issue a few days later.
4) Despite the infection control practice that takes place (or is supposed to)... I think our patients would be MORTIFIED if they knew the same MDI we bring them was also being used on every patient on the floor. (Even most of the nursing staff does not know that this practice is taking place.)
Again, I understand that hospitals are trying to save every dime. But, what is next? If a patient in the ER is on an IV drip of normal saline and then gets sent home and 400 ml remains in the bag...should we use a new IV set up but hook it up to the old liter of IV fluid so that we can bill both patients for the same bag of IV fluid? (Just food for thought.)
Despite my own beliefs on this issue, it is spreading across the nation like wild fire. I will be very curious to see how many of your facilities are using it now and how you feel about it.
Editor's Note: One Pennsylvania converted to a common canister policy and saved nearly $63,000 without any problems reported to the infection control department. Read about their experience with a common canister policy.