Q&A with Ann McKinstry, RPh
Performance Improvement Pharmacist
Rady Children’s Hospital

Pharmacy Purchasing & Products: What are some of the benefits of RFID technology?

Ann McKinstry, RPh: One of the main advantages of RFID technology is its inventory tracking capabilities. At Rady Children’s Hospital, we track our medication usage against the ideal quantity we should have on hand at any given time. We also run the analyses required for pointed efforts toward cost and waste reduction.

Primarily, we see these benefits with anesthesia trays, as these are our highest-use trays and contain a wide inventory of items. Other examples of RFID-tagged medication trays are emergency (Code) medication trays, emergency fluid trays, intubation trays, pharmacy code response trays, and patient transport trays. We rely on RFID inventory use data to direct our efforts at maintaining the RFID-tagged inventory necessary for pharmacy staff to do the work on a shift-by-shift and day-by-day basis, and to ensure that fast movers are consistently on hand within this inventory. Pharmacy runs RFID tray reports to pinpoint the locations of all the trays used by the anesthesia department in the last 24 hours, thus replenished trays are made available at the start of each surgical day. This also decreases time spent on the return and processing of trays that went unused.

Likewise, the process for monitoring expiration dates and recalls is simplified by leveraging RFID technology as we can locate the medication at any given time and capture that workflow. We are also able to monitor detailed controlled substance movement and chain of custody by tracking RFID tags as they move throughout the medication use system. The RFID software provides timed snapshots as a tray moves throughout the facility, including when pharmacy staff pick up the used tray, when it is returned to pharmacy, and when it is restocked and reenters circulation. Vendor workstation access is limited to anesthesia and pharmacy staff only. All anesthesia events including access, patient selection, and medication removal or return are recorded to the minute. Pharmacy can easily account for every single RFID-tagged medication. The RFID tag information includes the tag number, the manufacturer, the lot number, and the expiration date.

The technology also allows for automatic billing for anesthesia. Our vendor workstation allows the removal of an RFID-tagged medication out of any drawer, and once the drawer cycles and recognizes that a medication is removed, the medication appears on the patient record in the EHR at the same time. For RFID-tagged controlled substances, anesthesia staff can chart an administered dose and any associated waste, which then balances out and provides a sign-off on the reconciliation of the controlled substance. Billing occurs based on any RFID-tagged medication charted as administered within the patient’s EHR.

PP&P: What is the process for reviewing and refining policies and procedures related to RFID?

McKinstry: The pharmacy team typically reviews policies and procedures at a minimum of every 2 to 3 years based on the type of policy. However, as RFID technology changes, reviews and updates are often required more frequently. Evolving technology is one of our biggest drivers for re-educating or retraining staff, as well as ensuring that our documents reflect the current state of practice.

For example, our facility was an RFID pilot site for 2.5 years, and as such our vendor provided general standard operating procedure (SOP) documents that were not site-specific. While these documents outlined basic steps for using RFID technology, they did not necessarily apply to specific workflows within the pharmacy and throughout the hospital.

To address this, the first step was to observe the current workflow in the main pharmacy where RFID trays are returned and replenished, as well as the standard anesthesia workflow in the operating room in order to validate the existing SOPs against actual steps and then identify where the SOPs required more detail. This also provided an opportunity to identify any areas needing improvement. Improvement goals included decreasing waste and increasing efficiency, as well as identifying cost savings and quality improvement opportunities.

With an understanding of the workflows, we rewrote the SOPs so that they would serve as a direct resource for current staff and as a training tool for new staff. The pharmacy staff and anesthesiologists actively provide feedback, which supports continuous improvement efforts.

PP&P: How do you roll out improvements?

McKinstry: Training is a key element when implementing technology improvements and should be tailored to the level of the user. Pharmacy technicians and pharmacists have various levels of access to the vendor software and to the hardware, and anyone who requires high-level access is considered a super user and receives additional training. Access to the vendor workstations and software is reviewed monthly to confirm the level of access is appropriate based on the user role.

All documents are filed on our intranet and are readily accessible to the staff by computer. Staff actively use these documents and give feedback when there is a software upgrade or workflow change.

PP&P: Where have you found opportunities to streamline processes?

McKinstry: We have had the same square footage in the pharmacy for at least two decades while the number of patient beds has tripled. Pharmacy is required to keep more inventory and staff on hand to accommodate this growth yet square footage remains the same; consequently, space is incredibly limited.

In seeking opportunities for consolidation during the RFID SOP review, we found that the tray replenishment process left hundreds of trays on metal racks taking up precious pharmacy space. Under the previous process, a technician returned used trays to one rack, then moved replenished trays to another dedicated, labeled rack where they awaited the pharmacist’s final check. Finally, the trays were placed on yet another rack in the pharmacy to await deployment.

To streamline this process, I worked with the pharmacy technicians and identified delivery carts for the operating room as a storage solution. Now, every 24 hours we utilize four delivery carts for the used trays when they return to the pharmacy. Visual cues are used to indicate which trays are awaiting replenishment, the trays that have been replenished, and those trays awaiting a pharmacist check. Tray processing takes place on that same delivery cart, which simply rolls over to the vendor’s scanning cabinet for replenishment and a steps check. This process decreases waste and increases efficiency by removing the racks and using the delivery cart as the storage device for all stages of return, replenishment, final checks, and deployment. Once this process is complete, the delivery cart is ready to roll out the door and technicians no longer need to load a separate cart after these processes are done to prepare for final delivery.

See Part 2 of this series discussing RFID optimization in a future issue of Pharmacy Purchasing & Products.

Ann McKinstry, RPh, is a quality improvement pharmacist at Rady Children’s Hospital in San Diego, California.