Reducing Waste associated with Infliximab Infusion Bags

Project completed as part of the RUH Bath Green Team Competition. 

Team members: 

• Rebekah Hewitt (Senior Education & Development Pharmacist/Senior Teacher Practitioner, RUH) 
• Mandy Slatter (Pharmacy Practice Research Lead, RUH) 
• Megan Stevens (Clinical Pharmacy Technician for Biologics/Senior Aseptic Services Technician, RUH) 
• Rebecca Garrett (Rheumatology Senior Sister, RUH) 
• Sean O’Neill (Biologics Day Unit Charge Nurse) 
• Caroline Lock (Specialist Inflammatory Bowel Disease Nurse) 
• Rebecca Pennie (Interim Accountable Pharmacist for Aseptic Services and Radiopharmacy, RUH) 
• Alexandra Bushell (Operational Improvement Manager for Outpatient Transformation, RUH) 

Setting / patient group: Biologics Pharmacy, 

Issue:Medicines waste is recognised locally and globally as both a financial and environmental issue. It is estimated that the cost of medicines wasted prescribed within the NHS amounts to £300 million annually (Hazell and Robson, 2015). This project explores the possibility of reducing waste associated with a specific high-cost biologic medicine - Infliximab. Infliximab infusion bags are generally manufactured onsite at the RUH in the Aseptic Services Unit (ASU) using infliximab vials. The ASU is not licensed and so manufactured bags have a 7-day expiry as per Section 10 of the Medicines Act 1968. The number of patients treated each year using infliximab infusion bags manufactured on site at the RUH for IBD and RA is 576 and 90 respectively. In financial year 2023/2024, the Trust disposed of 76 infliximab infusion bags totalling 373 vials of biologic wasted. The production of an average Infliximab bag is estimated to be 164.85 kgCO2e. This represents 11% of all infliximab bags made on site. When infliximab bags are disposed of without being administered to a patient, there is both material and resource waste, and therapeutic loss. There are financial and sustainability implications as the manufactured products require several ancillaries per vial which are then wasted.

Primary Aim: 

Reduce waste of infliximab infusion bags by 30% by June 2025.

Intervention: Several opportunities for interventions were discussed (table 1 in full report)

Current efforts are being focused on making a change related to the communication between prescribing clinicians and those later on in the process. The BDU team is creating a Pool on Millenium. Once this is in place, formal communication will be sent out to all teams via email and the process explained at relevant departmental meetings. It is hoped that making an intervention earlier on in the process will have the greatest impact on reducing waste.

Potential Outcomes:

Patient Outcomes: Appropriate standard of care involves patients receiving their infliximab at the earliest clinically appropriate time. There may be legitimate clinical reasons, eg active infection, for delaying treatment but limiting non-clinical reasons for delay and improving early communication regarding appropriate cancellation will contribute to optimised therapy with minimal waste. 

Streamlining communication pathways around changes in the infliximab therapy schedule for all stakeholders using Millenium Pool should allow more efficient use of drug and “chair space” resource for patient benefit. 

Environmental:Annual savings if achieve project goal of 30% reduction in 2023/24 quantity of wasted product (reduce waste from 76 to 53 bags) = 3,791.55 kg CO2e. 

This is equivalent to driving 11,172 km in an average car

Financial: Annual savings if achieve project goal of 30% reduction in 2023/24 quantity of wasted product (reduce waste from 76 to 53 bags) = £6,674

Key learning point: 

This project has identified key opportunities for improvement supported by robust data 

Key contributors to success:

• Wide multidisciplinary stakeholder engagement
• Methodical QI approach
• Project support via the CSH team maintaining momentum and providing mentorship
• Perseverance in identifying alternative change ideas when initial options unworkable

The project report and incorporated QI tools will support continued engagement to implement change and sustain improvements. Identifying a project lead is critical alongside securing senior leadership endorsement. Any system changes must be formalised to ensure resilience. Submission to the Trust R&D abstract competition will support dissemination potentially via conference submission. Finally, if tested changes are seen to be beneficial, support to scale up across on-site aseptic medicines manufacture must be secured.