Rule No. 1 for James Babeshoff, CRNA: Don't open any anesthesia supplies until the patient enters the room. "Depending on the type of anesthesia I will be doing, then and only then do I open what is needed," says Mr. Babeshoff of Mercy Hospital in Clinton, Iowa.

To adhere to this rule, you can't be afraid to reach for what's needed when it's needed. No big deal, says Mr. Babeshoff. Anesthesia supplies are always within arm's reach from where the provider is situated in the OR, so why open endotracheal tubes or all of your airway adjuncts when it will only take you a few seconds to grab what you need? "Many anesthesia providers open up a selection of supplies on their cart that they never end up using," says Mr. Babeshoff, "and then have to throw them away at the end of the case because they're contaminated."

Take spinal trays, for example, says Mr. Babeshoff. You waste $25 in drugs and syringes every time you open a spinal tray and end up putting the patient to sleep. And what about drawing up a lot of drugs? "Don't open 10 syringes on the field and not use them," he says. "If you start irrigating during a bowel case and things get wet, you have to throw it away. Do that 2, 3 times a day, 5 times a month, that's quite a bit of waste."

When draping for regional anesthesia cases, Mr. Babeshoff uses sterile surgical towels that can be reprocessed rather than disposable drapes. "It costs a whole lot less to reprocess 4 towels than to open 2 different drapes," he says.

Here are more ways your anesthesia providers can save on supply costs.

Create an anesthesia charge sheet
You can empower (and encourage) your anesthesia providers to choose the most cost effective supplies and drugs by creating an anesthesia charge sheet that lists the price of every item they might use for a case, says anesthesiologist William Hass, MD, of Crestwood Medical Center in Huntsville, Ala. You can list supplies on one side and drugs on the other, and include a space for write-in items and a patient sticker.

"This sheet gives you a better idea of what it costs to do a case," says Dr. Hass.

For example, he says, you might have a choice of 2 muscle relaxants, each safe and effective. One costs $23 a bottle, the other $4 a bottle. Seeing this in black and white is a good reminder to consider the more economical agent, says Dr. Hass.

Saving on inhalation agents
The use of low fresh gas flows is key to controlling the cost of the anesthetic. It's easy to overlook the cost of inhalation anesthetics and hard to break the habit of running higher fresh gas flows than you really need, says M. Craig Pinsker, MD, an anesthesiologist in Glen Allen, Va. For one, gases are invisible, unlike the ampoule of IV drugs you can hold in your hands that has a price associated with it. "With vapors, you really don't know how many cc's you're using. You just put it in your vaporizer and you set your number," says Dr. Pinsker.

But a simple way to save is to use the minimum fresh gas flow necessary when using inhalation anesthetics. Let's say, for example, that you're using desflurane at <0.4L flow. If a 0.3L flow keeps the bag or ventilator filled, any additional flow is waste and more contamination of the environment, says Dr. Pinsker.

John P. Abenstein, MD, an associate professor of anesthesiology at the Mayo Clinic in Rochester, Minn., recommends that you mandate low fresh gas flows in all cases — 1L/min or less, for example.

If, like most anesthesia providers, you use fresh gas flows in the 3 to 5L/min range, much of the fresh gas goes in and out of the lungs and is then disposed of, says Dr. Abenstein. Lower flows (1L/min or less) means that the patient re-breathes the gases and the carbon dioxide absorber gets rid of the expired CO2. "The re-breathing means that expensive inhaled anesthetics aren't wasted," says Dr. Abenstein. "This can add up to real savings over a year. There is increased cost for more expended carbon dioxide absorbers, but it's a fraction of the savings on inhaled anesthetics."

Another way Dr. Abenstein says you can save on inhaled anesthetics: Use only isoflurane, a very inexpensive inhaled anesthetic compared to sevoflurane and desflurane. If sevoflurane is needed for induction, you can then switch to isoflurane.

"The claims that sevoflurane and desflurane will save money because patients wake up faster is to some degree true, but the incremental expense of these medications greatly offset these savings," says Dr. Abenstein. "You have to pay a bit more attention, but an experienced clinician can easily wake most patients up as soon as the surgeon is done when using isoflurane."

Use regional anesthesia
For anesthesiologist Ben Jacobs, MD, of the Paoli Surgery Center in suburban Philadelphia, it pays to use regional anesthesia as an alternative to general anesthesia whenever possible. The cost-savings benefits? Decreased supply costs and decreased recovery room stay (as a result of less nausea and vomiting and pain), which leads to decreased nursing costs as staff go home earlier, he says.

The costs for regional anesthesia include local anesthetic, block supplies, sedation and routine monitoring. Compare that, says Dr. Jacobs, to the cost for general anesthesia: sedation, expensive volatile anesthetics, routine monitoring, perhaps consciousness monitoring and anesthesia supplies including breathing circuits and endotracheal tubes/LMA. Plus, there are more drugs commonly used in recovery for pain control.

Use generic line and regional anesthesia kits rather than custom kits, says Dr. Abenstein. "A basic kit is all you need and additional items can be added when needed," he says. "For example, a total body drape in a neckline kit can cost up to $10 more per kit. A back table disposable drape is about $1.50 — and does the same thing."