University of Pennsylvania Department of Electrical and Systems Engineering Authors: Thalia Shamash ESE ‘09 Daniel Hillm

1. RxPunge: Pharmaceutical Waste Disposal System for HUP University of Pennsylvania Department of Electrical and Systems Engineering Authors: Thalia Shamash ESE ‘09 Daniel Hillman ESE ’09 Ethan Keller ESE ‘09 Emily McGrath ESE ’09 GROUP #14 Advisor: Dr. John Keenan Data Collection: Two separate studies were conducted in which wasted medications were meticulously documented: I: RxPunge driven study ~ 11/21/08 – 12/14/08: Over 1,400 IV bags were processed twice a day. Analysis focused on drug type, IV volume, and quantity of active drug. Data assisted with formulation of drug categories and helping guide disposal and treatment research. II: HUP driven study ~ 2/24/09 – 3/16/09: Over 1100 IV bags were recorded. Data contributed to understanding of IV preparation times, expiration dates, and cost structure. After the data collection, RxPunge categorized the drugs into over 40 categories. Five of the most abundant categories were chosen for analysis because of their large numbers and adverse impacts. These were antibiotics, hormones, vasoactive drugs, anti-seizure drugs, and antiviral drugs. Background: In thousands of medical facilities and millions of homes throughout the country, medications are consumed on a daily basis. Hospitals generate large quantities of medical waste, including biohazard, sharps, and others, which are regulated and disposed of safely. A large gap exists with regard to pharmaceutical waste that has not been explicitly designated as hazardous. This waste has been shown to cause harmful effects on natural ecosystems. Furthermore, recent research has indicated that such medications are present in natural and municipal water sources. In fact, researchers with the U.S. Geological Survey have reported the presence of various antibiotics just downstream of hospital and municipal wastewater treatment plants in a number of states. Drug Distributions: Vasoactive Drugs Antiseizure Drugs Antiviral Drugs Drugs in the Environment: • Data Findings: • 44% of the drugs recorded were antibiotics • Top 5 categories of interest represent 67% of total drugs recorded • 4% of containers collected are “hazardous” according to OSHA • Highest drug waste occurs on weekends • Critical Care units have the largest amount of waste • Ten drugs account for 68% of waste costs • 70% of these drugs on average are administered to a patient more than once a day • 50% have expiration dates longer than a day Hormones Antibiotics Antibiotics • Increase propagation of antibiotics-resistant bacteria strains • Kill off healthy ecosystem bacteria and microbial algaes Abstract: There is a growing concern in the medical and environmental communities regarding the current disposal methods for pharmaceutical waste. The practice of discarding expired pills and intravenous solutions in sink drains of hospitals compromises the safety of our water and environment. RxPunge has worked closely with the inpatient pharmacy at the Hospital of the University of Pennsylvania (HUP) to study the IV waste system in place and to assist the pharmacy in pioneering a new system to properly classify, manage, and dispose of these dangerous chemicals. RxPunge recorded quantities and types of expired IV drug solutions returned to the pharmacy to assess the current system in place. Over 150 drugs were classified and evaluated for hazard, reactivity, biodegradation, and potential disposal methods. Statistical distributions were identified to simulate the drug disposal, and these were used to develop a stochastic simulation to predict the daily mix of pharmaceutical waste. This model, combined with implementable recommendations, depicts a method to better manage pharmacy operations and reduce hazardous waste. Inventory practices, drug-preparation times and distribution frequencies can be modified to reduce drug waste from the hospital and cut costs. Waste disposal and treatment methods were analyzed, thereby providing actionable options with which HUP create positive environmental impact. Hormones Disposal and Treatment: A thorough review of Material Safety Data Sheets (MSDS) was conducted in order to evaluate drug toxicity. Drugs were rated based on flammability, solubility, environmental hazard and toxicity. These parameters determine how expired drugs will be collected in containers, mixed with other waste, and transported. Waste disposal and treatment methods were analyzed, providing actionable options with which HUP can mitigate its environmental impact. Based on consultations and research, the most practical and cost-efficient method of disposal is incineration. Potential incineration sites in the Philadelphia area were identified, with costs, shipping distances and safety features considered. The RxPunge model was used to simulate expected waste volumes and then was employed to determine collection frequency and receptacle size. • Disturb endocrine systems, impair, and adversely effect biological characteristics of humans and wildlife (e.g. feminized fish) Collaboration: RxPunge conducted a careful review of regional hospitals, ultimately choosing the Hospital of the University of Pennsylvania (HUP) as the most appropriate partner. Reasoning included HUP’s stature as a cutting edge hospital which pioneers industry standards in addition to the willingness of key management to partners with Penn Engineering students. Planning meetings with hospital management helped identify Intravenous (IV) waste as the primary subject for analysis. RxPunge has since developed a close relationship with directors of the Inpatient Pharmacy and has conducted bi-weekly meetings on site. The first stage in RxPunge’s analysis was to examine the current process within HUP (as depicted in blue in the chart below). Key decision nodes affecting waste output were identified (orange) as main components of a potential RxPunge solution. The Inpatient Pharmacy serves as a hub for storage, dispatch, and sorting of pharmaceutical inventory. Medication solutions are mixed and sent out to the floors. Drugs not administered to patients are returned to the pharmacy during pick up rounds that occur twice a day. Upon return, unexpired drugs are recycled, and expired medicines are poured into an industrial sink in the IV processing room. • Recommendations: • RxPunge Inventory Solution: • Incorporating additional drug deliveries runs within HUP • Elimination of bulk preparation for uncommon drugs • Same day preparation to extend expiry time • Better enforcement of FIFO inventory management • RxPunge Disposal Solution: • Collection and categorization of expired drugs • Transportation to and incineration in 1 of 3 identified waste management sites • Collection of waste from outside management once per month • While currently infeasible, sewage treatment will provide a more comprehensive solution in the future. The RxPunge Model: This model depicts the current pharmacy waste output. Using the collected data and sophisticated statistical software, disposal distributions were backed-out to represent medication categories that were returned to the pharmacy. Random variables were generated according to these distributions. Assumptions were made based on interviews with pharmacy personnel. These data were used to simulate expected dispatch, returns, and waste of various drug categories on a given day. DEMO TIMES: Thursday, April 23rd 2009 AM: 9:00, 9:30, 10:00 PM: 3:00 Block diagram of process stages and locations for drug disbursement in HUP Blue: Existing Process Orange: Proposed Modifications Assumptions: % drugs that go out a day are returned ~ N(30%, 2.5%) % drugs that are returned are expired ~ N(30%, 5%)