App may help cut costs from OR drug budget

Looking for OR Drug Savings? There’s an App for That

By Michael Vlessides

San Diego—Health-system pharmacy leaders tasked with cutting drug budgets may find that a simulated anesthesia app may help save both time and money in in the near future.

Researchers at the University of Florida College of Medicine, in Gainesville, said the panoramic, screenbased simulator is particularly adept at assessing the cost of administering, monitoring and reversing neuromuscular blockade, while also considering drug costs and the cost of associated operating room time.

“Given the continued incidence of residual postoperative neuromuscular blockade, along with the fairly recent FDA approval of sugammadex [Bridion, Merck], there is renewed interest in fine-tuning the monitoring and reversal of neuromuscular blockade,” said Samsun Lampotang, PhD, the Joachim S. Gravenstein Professor of Anesthesiology at the University of Florida Health. With this in mind, Dr. Lampotang and his colleagues developed the interactive app, which he said was specifically designed to enable users to practice the administration, monitoring and reversal of neuromuscular blockade.

The app was built in Adobe Director, a now-discontinued authoring platform for multimedia applications, to simulate various anesthesia activities in the OR. Although the app uses only one computer screen to simulate the entire OR environment, users can pan around the entire room.

A range of simulated activities and equipment are represented, including video clips of intubation and laparoscopy. The app also simulates such equipment as a neuromuscular blockade monitor, an anesthesia machine with user-adjustable flow meters and vaporizers, gas analysis (which models breathing circuit dynamics like wash-in and washout), and physiologic monitoring.

Pharmacokinetic and pharmacodynamic parameters from official package inserts were used by the developers to mimic a host of related drugs, including sevoflurane, isoflurane, glycopyrrolate, neostigmine, succinylcholine, fentanyl, propofol, rocuronium and sugammadex.

Navigating the Simulation

To help users assess the clinical and financial effects of their actions, the app incorporates an event log, which captures all user actions throughout the simulated case. This tool allows clinicians to go back in time and undo mid-case events, and even make a different decision without restarting the scenario. The models then forecast relevant parameters for each new user interaction for up to three hours. Finally, a scrolling time line gives users the opportunity to jump forward and backward in time, either to skip periods of inactivity or to undo a previous action. It is this kind of functionality, Dr. Lampotang explained, that allows users to see the potential costs and savings inherent in using a particular neuromuscular blockade reversal strategy.

Using an innovation the researchers call a “taxi meter,” the app also displays the cost of the procedure on a minute-by minute basis. Using a baseline OR cost of $100 per minute, it illustrates the financial impacts of clinicians’ decisions, such as the time to complete recovery from deep neuromuscular blockade.

“This is where sugammadex shines,” Dr. Lampotang said. “Using a typical simulated patient, we assume that a drug like rocuronium will take considerably more than 40 minutes to clear out of the patient’s system on its own. Using neostigmine or glycopyrrolate, that drops to approximately 20 minutes. But if you use sugammadex, you’re going to reverse the patient in a minute or two. So you’ve saved 18 minutes,

which we calculate as an immediate savings of $1,800.”

The researchers verified the app, which was presented at the 2022 Society for Technology in Anesthesia annual meeting, in Las Vegas, by comparing the output of each model with its source material, such as the package insert. It was found that drug concentrations, clinical durations and recovery times on the app matched these materials. Anecdotally, anesthesiologists who used the app said its output also matched their clinical practice.

Unique App

Ratan Banik, MD, PhD, an assistant professor of anesthesiology at the University of Minnesota Medical School, in Minneapolis, and the cocreator of an iPhone app that assesses the train-of-four ratio, said he believes the app helps fill a void in the simulation world, and will likely improve clinical practice. “Many clinicians have a hard time grasping the concept of quantitative neuromuscular blockade because these devices are unavailable at many institutions. Even when they are available, we tend to use them only for research purposes,” he said. “So if we can teach people through a simulated environment, all the better.”

Drs. Banik and Lampotang reported no relevant financial disclosures.