Financial Benefits for Oxford HELP® Users
The Oxford HELP® saves hospitals money immediately by dramatically reducing the amount of disposable equipment that would otherwise be used coping with difficult anaesthetic situations, particularly difficult intubations. A hospital performing as few as 7,000 general anaesthetics annually could expect to save at least £400 per annum from the cost of disposable use if it used the Oxford HELP® on all morbidly obese patients presenting for elective surgery. This is because the HELP® reduces by 90% or more the occurrence of the difficult intubations during which clinicians have to turn to disposables such as bougies and video laryngoscopes for assistance. For many large teaching or district general hospitals with obstetric and bariatric lists, the savings from routinely using the HELP® can easily exceed £1,800 per annum. The Oxford HELP® is primarily intended to increase patient safety and welfare during anaesthesia, but its dramatic ability to reduce disposable consumption means that many orders are likely to repay their capital cost in financial savings within two years of purchase.
The following table is intended as a guide to the financial savings hospitals of different sizes and surgical populations could expect to realise in their first year of using the Oxford HELP® A detailed explanation of the figures is provided below.
* All figures rounded to the nearest £100; actual estimated figures £1197.85, £1796.74, £2994.57.
Explanation of Financial Calculations
I: Routine Elective Surgery
1% of the UK population are morbidly obese (BMI ≥40kg/m2). Thus a hospital performing 10,000 general anaesthetics a year will have 100 morbidly obese patients, assuming that morbidly obese patients will occur at least as commonly in the surgical population as they do in the general population.
Using the statistics from a study of morbid obesity and tracheal intubation by Ndoko et al,1 21 of 100 patients with BMIs over 40 intubated with a standard Macintosh laryngoscope will require bougie use for a successful intubation, and, of these, 11 will have airways so difficult (tracheal intubation not achieved within 120s) that an alternative method will be used, such as a video laryngoscope. The latter situation would inevitably require a second administration of the preferred induction agent.
Bougies differ in price considerably, but the cheapest are rarely less than £4 (inc vat).2 The Airtraq®, a representative video laryngoscope, tends to cost at least £47 (inc vat) per unit.3 Propofol, a highly popular induction agent, costs £4.18 per 20 mL amp.4 The combined cost of bougies, video laryngoscopes, and induction agents used in response to difficulties with intubation in 100 morbidly obese patients can thus be expected to be at least £647 per annum, based on a predicted expenditure of 21 bougies, 11 Airtraqs® or other video laryngoscopes, and 11 additional doses of Propofol.
This is a very conservative figure, since it excludes the costs arising from obesity-related difficult intubations of patients of BMIs between 30 and 40, and, because the morbidly obese patients in the Ndoko study had an average BMI of 43, it generously assumes that the proportion of super-obese (BMI ≥50kg/m2) patients within the notional 100 patient sample considered here will not require additional expenditure of disposables.
In the crucial study by Brodsky5, use of the head elevated position with morbidly obese patients undergoing elective surgery resulted in 99 successful intubations without any need even for bougies, and 1 failed intubation. The results of the study suggest that use of the head elevated position with morbidly obese patients could result in a 99% reduction in the use of disposables, with the rate of failed intubation being no different from that found in the normal surgical population.
Conservatively, we predict a 90% reduction in disposable use where the Oxford HELP® is used in intubating morbidly obese patients with standard Macintosh laryngoscopes as the first choice piece of equipment. Thus, the hospital in this example performing 10,000 general anaesthetics per year would see the cost of obesity-related disposable use during intubation cut from at least £647 per annum to £65 per annum, assuming that, as we recommend, all morbidly obese patients are intubated using the Oxford HELP® pillows to produce the head elevated position.
A hospital performing 10,000 general anaesthetics per year as part of routine elective surgery might thus expect to realise at least £582 in cost savings during the first year of using the Oxford HELP®, in addition to the substantial benefits to patient welfare and safety explained elsewhere in this business case.
II: Obstetric General Anaesthetics
We recommend that the HELP® is used whenever a general anaesthetic is given to an obstetric patient. Statistics for the incidence of difficult intubation during obstetric general anaesthesia vary greatly, from the 1:16 reported by Rudra (2005), quoting Roche et al (1992) and Samsoon & Young (1987)678, to the 1:30 reported by McDonnell et al (2008)9, to the 1:149 reported by Djabatey & Barclay (2009)10. This wide variation is partly the result of differing definitions of difficult intubation. We use the estimated figures of 1:65 (the average of the three figures above) obstetric general anaesthetics being mildly difficult intubations requiring the use of a gum elastic bougie to achieve intubation, and 1:125 for the much rarer case of an intubation difficult enough to require a fallback to the use of a video laryngoscope and time-consuming enough to require the administration of a second dose of the induction agent. The 1:125 figure is derived from the ratio of bougie use to video laryngoscope use in difficult intubations reported by Ndoko (2009), which found that 0.52 video laryngoscopes were typically used for every one bougie.
Using the figures given above of a minimum of £4 for a bougie and £47 for an Airtraq®, and the BNF price of £3.06 for a dose of Thiopental11, a popular induction agent for obstetric general anaesthesia, the combined cost of the additional drugs and disposables used in response to difficult intubation in obstetric general anaesthesia can be calculated as being at least £184 per annum for a hospital performing 400 obstetric general anaesthetics per year. This is based on a predicted expenditure of an average of 6.15 bougies, 3.2 Airtraqs®, and 3.2 additional doses of Thiopental for every 400 obstetric general anaesthetics.
Conservatively, we predict a 90% reduction in disposable use where the Oxford HELP® is used in intubating obstetric patients with standard Macintosh laryngoscopes as the first choice piece of equipment. Thus, a hospital performing 400 obstetric general anaesthetics per year would see the cost of disposable use during intubation cut from at least £184 per annum to £18 per annum, assuming that, as we recommend, all obstetric patients are intubated using the Oxford HELP® pillows to produce the head elevated position.
Thus, the use of the HELP® in obstetric cases can be expected to produce further savings of at least £166 per annum, using conservative estimates and figures from published studies.
III: Bariatric Surgery
For hospitals that perform bariatric surgery such as gastric banding, there will naturally be an additional number of morbidly obese patients presenting for surgery. Using the same mathematics and conservative extrapolations as for Part I above, a hospital performing 100 bariatric operations per year could be expected to incur an additional £647 cost for the disposables needed to assist intubation of these patients, with routine HELP® use on all bariatric lists cutting the cost to £64, and delivering a saving of £582. This is still a conservative estimate, since it excludes the impact that the inevitably larger number of super- and hyper-obese patients presenting for bariatric surgery than for other types of surgery would have on disposable consumption.
(*All figures and statistics correct as of 2011)
1 S. K. Ndoko, R. Amathieu, L. Tual, C. Polliand, W. Kamoun, L. El Housseini, G. Champault, and G. Dhonneur Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and AirtraqTM laryngoscopes, Br. J. Anaesth. 2008; 100: 263-268.
2 Proact Medical Ltd, 2010 prices, available from http://www.proactmedical.co.uk/home.htm
3 Boundtree Medical, price in July 2010 from website (http://www.boundtree.co.uk/Scripts/prodView.asp?idproduct=2154)
4 British National Formulary 59
5 Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid Obesity and tracheal intubation, Anesth. Analg. 2002; 94: 732-6
6 Rudra, A. Airway Management in Obstetrics, Indian Journal of Anaesthetics, 2005; 49 (4): 328-335
7 Rocke DA, Murray WB, Rout CC, Gowus E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia, Anesthesiology 1992; 77: 67-73.
8 Samsoon GLT, Young JBR. Difficult tracheal intubation: A retrospective study, Anaesthesia 1987; 42: 487-90.
9 N.J. McDonnell, M.J. Paech, O.M. Clavisi, K.L. Scott, Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section, International Journal of Obstetric Anaesthesia 2008; 17 (4): 292-297
10 Djabatey, E., and Barclay, P., Difficult and failed intubation in 3430 obstetric general anaesthetics, Anaesthesia 2009; 64: 1168-1171
11 BNF 59