Fundamentally, automated dispensing cabinets (ADCs) are computerized drug storage devices designed to securely store and dispense medications in close proximity to the point of care, while also enabling automated tracking of drug distribution. ADCs offer a variety of benefits to the organization and the user, as they provide nurses with easy access to medications, which helps decrease medication order and delivery turnaround times in comparison to the traditional practice of ordering medications to be delivered from a large central pharmacy inventory. ADCs and their accompanying software also are capable of providing robust security against possible theft and diversion, a comprehensive audit trail for controlled substances use, and improved charge capture. 

Beyond these fairly basic functions, current ADC hardware and software can provide additional support to clinicians, including bar code scanning during cabinet restocking, integration of dispensing data into automated medication refilling systems, and approved drug safety alerts and decision support when selecting medications; all of which help improve patient safety. In addition to these helpful features, perhaps the most valuable ADC safety enhancement advanced over the last decade is the ability to profile the cabinets, enabling a pharmacist to review and approve medications remotely before they are made available for selection and administration. Effectively, a profiled ADC is one that compels practitioners to select a drug from a patient-specific list on the ADC screen and obtain that medication only after the order has been verified by a pharmacist.¹ Furthermore, this capability supports TJC’s standard MM.05.05.01, EP 1, which mandates pharmacist review of all new orders prior to medication dispensing.

Growing Dependence on Profiling
According to a 2011 national ASHP survey of pharmacy practice in hospital settings, a majority of hospitals (89%) use ADCs in their medication distribution systems.2 While the use of ADCs differed by hospital size (more than 97% of hospitals with 200 or more staffed beds use ADCs compared to 78% of hospitals with fewer than 50 beds) 96.2% of those hospitals with ADCs use patient-specific medication profiles, a practice that has seen significant growth in the last decade (see Figure 1).²



Martha Jefferson Hospital, a 176-bed community hospital within the Sentara Healthcare system, has employed profiled ADCs in the inpatient setting since the early 1990s. Subsequent automation implementations included a central robot in 2000 and a carousel and high-speed packager in 2007; the latter of which allowed us to package medications fully in-house as opposed to outsourcing that process. Currently, we operate a hybrid medication distribution model with standing orders filled from the central robot and carousel, and PRN and controlled substances made available from unit-based ADCs. These automation initiatives served as a foundation for the adoption of bar coded medication administration (BCMA) in our inpatient units beginning in May of 2008. 

Since that time, we have added BCMA, which charts on an electronic medication administration record (eMAR) subsequent to medication scanning, and CPOE (September 2012) to our emergency department (ED), as well as our freestanding ED. Initially, the addition of BCMA and eMAR functionality required the pharmacy to manually enter orders into our hospital information system (HIS) for those units, which led to an increase in pharmacy labor, but we felt the potential safety gains were compelling enough to absorb that increase. Our ultimate goal was to streamline and standardize as much of the medication management process in the outpatient setting as possible, and this included making the proper arrangements for profiled ADCs.

Impact of Profiling on Medication Acquisition
When we began the process of profiling ADCs at Martha Jefferson, we initially profiled cabinets on inpatient units where they allowed easier access to certain medications, such as controlled substances and PRN medications, but still provided the security and peace of mind of pharmacist review. Our nurses have come to appreciate profile dispensing because it offers easy identification of those medications ordered for a specific patient, as opposed to having to scroll through the entire cabinet inventory to find what is needed. However, if pharmacist review of orders is not timely enough, nurses can become frustrated by what they see as a delay in treatment. Hence, the ability to override the pharmacist review process is necessary to allow nurses access to medications when there is an emergent need. 

Given this, certain medications are designated as overridable, but those that are not cannot be accessed in the ADC prior to pharmacist review. Furthermore, our state board of pharmacy mandates the review of overrides, so the percentage of ADC vends that are overridden should be monitored for excessive or irregular use. Proper use of overrides should be clearly delineated in policies and procedures as limited to situations where waiting for a pharmacist review has the potential to cause patient harm. 

Effect of Profiling on Distribution Model
Many health care organizations have moved beyond storing only controlled substances and floor stock in ADCs, and are now using ADCs as their primary method of drug delivery. This shifting trend in pharmacy distribution from centralized to decentralized/point-of-care has had broad implications for pharmacy and nursing workflow, and the safety of associated practices.1 The percentage of hospitals using a decentralized medication distribution model is increasing, having doubled from 20% of hospitals in 2002 to 40% in 2011.2 While the process of determining which model among centralized, decentralized, or hybrid works best for your facility is practice dependent, all variations on these models have risks and benefits. However, utilizing the profile function of ADC systems whenever possible, including in outpatient areas such as the emergency department, is one method to mitigate medication storage and administration risks in any given model. 

In the ED or procedural areas, medications tend to be ordered with the intent of expedited administration, so developing a process to promptly address those orders in the pharmacy can be challenging. Hence, the development and implementation of profiled dispensing creates a safety net that historically has not been present in outpatient areas. The ability to check for appropriateness of dosing, allergies, interactions, etc, prior to administration helps to provide the same level of care in outpatient units as inpatient units when using profile dispense functions. 



Gaining Control Over Outpatient Medication Management
When we first began using ADCs in our outpatient and procedural areas, such as the ED, all of the cabinets were set on inventory dispense mode, which meant that if a nurse accessed an ADC, he or she had access to all of the medications housed in that cabinet. The outpatient/procedural ADCs were set this way because pharmacy was rarely involved in entering orders into the hospital information system or reviewing medication orders in these areas, so setting a profile functionality for these ADCs was inapplicable at the time. As we implemented BCMA throughout the hospital in 2008, we began the process of having selected outpatient areas charting on the eMAR as well, followed by the activation of profile dispensing. The emergency departments—both main and freestanding—were among the first outpatient areas to implement BCMA and switch to profile dispense with their ADCs.

Process Change in the Emergency Department
When the administrative responsibility for emergency services was brought under the purview of the pharmacy director in 2008, it provided an opportunity to evaluate processes for improving safety in that department. The ED is an area where pharmacy had little previous involvement and where there is significant potential for error due to the hectic environment and rapid pace of work. Prior to expanding the eMAR and BCMA into the ED, the pharmacy would only enter orders into the HIS for medications not stored in ED ADCs and which had to be prepared and sent from the central pharmacy. In order to help standardize the entire medication administration process, we began by entering all ED medication orders into the HIS, not just those that needed to be sent from the central pharmacy. 

At the same time, our nurses were expected to begin charting in our eMAR instead of charting on paper; a process that has resulted in a significant improvement in documentation accuracy. Additionally, if patients are admitted from the ED or another outpatient department using eMAR, the inpatient nurses receiving those patients can quickly see any medications that were previously administered because they share the same documentation platform. 

This transition signaled a significant process change for the ED nurses who were used to documenting orders on paper and administering medications without regard to pharmacy order entry. In relatively short order, the ED nurses grew to support the new process because they understood the value of having their documentation more readily available to nurses to whom they were handing off, as well as other clinicians along the continuum of care. Of note, one of the biggest challenges to this transition was making sure that patient allergies were being documented in the electronic record; a requirement for pharmacy to complete order entry and review. 

In the summer of 2011, we expanded our BCMA adoption to the EDs, which provided an additional safety net for medication administration, especially considering those units were still using inventory dispense. At the same time, we also began a new initiative that has proven particularly beneficial, which was to place a pharmacist in the ED for one shift a day. This has helped pharmacy gain a better understanding of—and subsequently become more engaged in—the critical provision of expedited medication review in that practice environment. In addition to order entry and review in the ED, the pharmacist was given responsibility for gathering medication history on ED patients that were being admitted. This allowed the ED nurses to focus on other activities and also proved beneficial to our physicians responsible for admission medication reconciliation, as they would begin that process with a more complete home medication list. Accordingly, nurses and physicians in the ED now see their pharmacist as an important asset to the provision of quality care.

Once these processes were implemented, we were finally ready to switch to profile dispense in the EDs. We knew from the beginning that it would be a long journey from inventory dispensing and paper charting to electronic medication administration, bedside scanning, and profile dispensing, so we made changes incrementally, which made the process more palatable for all involved. 

Bringing About Process Change
When we first began the project of profiling ADCs in the ED and other outpatient areas, we engaged pharmacy leadership, including the pharmacy director, the ED manager, shift coordinators, and educators, to begin the discussion of altering our medication distribution processes. Once our staff understood what we were trying to accomplish, they helped us fine-tune the plan for maximum efficiency. One incentive to using profiled dispensing is the ability to place medications in the cabinets that would not normally have been accessible when using inventory dispense mode. 

Once profile dispensing was initiated, we added several antibiotics to the ED cabinets, which helped shorten the time between order and administration, as once the order was entered and reviewed by the pharmacist, the nurse could remove the antibiotic from the cabinet right away rather than having to wait for the dose to be delivered from the central pharmacy. This also helped us improve our time to first dose of antibiotics for pneumonia and sepsis patients. This process was initiated in three different areas—the main ED, the minor emergency care area, and the free standing ED, where the transition was especially useful, as the facility is distant from the main hospital and by necessity must have more drugs stocked in their ADCs. 

Managing Overrides
Given of the nature of the work in the EDs, there are more drugs available on override than on most inpatient units, as we cannot afford to delay care in the event the pharmacy cannot review medication orders quickly enough to meet urgent patient needs. This is especially critical on the night shift when there is only one pharmacist available to review orders for the entire hospital. Fortunately, overrides have been minimized in our EDs by what is usually a very good turnaround time for order review. 

Medications that are available for override include injectable pain medications, reversal agents, critical drips, and antiemetics, among others. All decisions regarding which drugs would be allowed for override were made with input from the medical director of the ED and adjustments have been made when those decisions resulted in problems in care delivery. For example, we have triage protocols in the EDs that can be implemented prior to a physician seeing a patient and entering orders, so we had to make the medications associated with those protocols overridable. These include products such as oral pain medications for flank pain, which were not initially overridable. 

Conclusion
Ultimately, the key to our success in profiling ADCs in the EDs included the consensus among pharmacy and nursing that we could make medication processes in these areas safer. Having the pharmacy and emergency departments under the same director also has proven beneficial, as we were able to develop a natural liaison between the two departments when issues needed to be resolved. While we could have had similar results without placing a pharmacist in the ED—and there is no pharmacist placed in the freestanding ED—that placement did help in clarifying issues and providing more focus. 

ADC profiling in the EDs has been a successful endeavor for more than a year now and in the meantime, we also have implemented profile functionality in the day surgery unit, which has allowed us to place preoperative antibiotics in their cabinets. This functionality clearly helps bring vital medications closer to the point of care without sacrificing the critical step of pharmacist review. We hope to continue finding ways to profile the process of medication distribution throughout the hospital.

References

1. Institute for Safe Medication Practices. ISMP 2008 Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets.Available at: www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf
2. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011. Am J Health-Syst Pharm. 2012 May 1;69(9):768–85.

Janet A. Silvester, RPh, MBA, FASHP, is the director of pharmacy and emergency services at Martha Jefferson Hospital, and also serves as one of the preceptors in the pharmacy practice management rotation. She received her BS in Pharmacy from the Medical College of Virginia/Virginia Commonwealth University and her MBA from James Madison University. Janet is currently a Doctor of Pharmacy candidate at Creighton University. She is a former president of ASHP.