Discarded intravenous medication in the ICU: the GAME-OVER multicenter prospective observational study

Abstract

Background: Medication waste is a contributor to the healthcare environmental footprint and impacts ecosystems. Data on medication waste in the intensive care unit (ICU) are scarce, and therefore are essential to develop new sustainable strategies.

Methods: The GAME-OVER French multicenter prospective observational study was conducted from November 2022 to March 2023, over a 24-h period of choice, at the discretion of each participating center. Adult ICUs were enrolled in the study on a voluntary basis and hospitalized patients who did not express opposition were included in the analysis. The primary endpoint was the percentage of discarded intravenous (IV) medication in the ICU, defined as the ratio of the discarded volume to the total volume of IV medication prepared. Secondary endpoints included identifying risk factors and main reasons for medication waste and estimating its related healthcare cost.

Results: Among the 81 ICUs and the 1076 enrolled patients, 408.9 L of 130 IV medications were prepared. The discarded volume was 43.8 L, resulting in a 10.7% discarded IV medication (95% Confidence Interval (CI), 9.9-11.5). Number of daily admissions/discharges in the ICU, as admission for elective surgery, Sequential Organ Failure Assessment score ≥ 7, endotracheal intubation, renal replacement therapy and body mass index were independently associated with increased discarded IV medication. Ninety percent of pharmaceutical waste was attributed to 25 key drugs, with an estimated national annual cost of 2,737,163€.

Conclusions: Discarded intravenous medication in the ICU is considerable and results in significant costs for the health care system, without obvious patient-centered value. Risk factors associated with medication waste were largely nonmodifiable, emphasizing the need for sustainable practices in patient care and resource management.

Trial registration: ClinicalTrials.gov: NCT05553054 . September 23, 2022.

Keywords: Drug waste; Ecodesign of healthcare; Environment; Healthcare cost; Pharmaceutical waste; Sustainable healthcare.

Fig. 1

Multivariate analysis of patients-related risk factors for discarded intravenous medication. An Odds Ratio greater than 1.0 indicates an association with increased discarded intravenous medication. Multivariate analysis was performed using a backward stepwise logistic regression model after selecting variables with a p-value < 0.2 in univariate analysis: age, body mass index, indication for intensive care unit (ICU) admission, total Sequential Organ Failure Assessment (SOFA) score, continuous sedation, upper airway access, oxygen therapy, renal replacement therapy, enteral route available, patient discharges on the study day, ICU length of stay. The optimal categorization of the SOFA score, a continuous variable into separate categories was obtained with the CatPredi model (Hosmer–Lemeshow test p = 0.18). A p value < 0.05 was considered significant

Fig. 2

The 25 most discarded medications in the overall cohort. The percentage of volume disposed (orange bars) represents the ratio of the volume disposed of the molecule to the total discarded volume of the 25 most discarded medications. The average price of each medication per milligram (or international unit (IU) for insulin and heparin) was calculated using prices obtained from 3 different hospitals. Solvents, medical devices, and preparation time were excluded from the estimated cost. The percentage of waste cost (blue bars) represents the price of the amount of mg (or IU) thrown away per molecule to the total cost of the 25 most discarded medications