Located in Kirkland, Washington, Evergreen Healthcare includes nine primary care clinics, a hospice, surgery center and a 250-bed tertiary community hospital. Our services include a level IV emergency room, general surgery, cancer and cardiac care, orthopedics, NICU and OB/GYN. The average midnight census in 2008 was 190.

Medication distribution is centralized with a daily unit dose medication exchange and first doses are dispensed from the hospital pharmacy. We also have satellite services in the NICU and OR. Medications are delivered by couriers and technicians while a pneumatic tube system is utilized for STAT and rush orders.

Since 1992, routinely scheduled medications have been delivered to nurse servers located outside each patient room. This system is labor intensive for the pharmacy, but having medications as close as possible to each patient increases patient safety and nursing convenience.
Although we just implemented BCMA last year, the process of creating a distribution system that could support both BCMA and preserve the nurse server model was many years in the works. We began in 2004 by installing a dispensing robot and unit-based automated dispensing cabinets (ADCs). The robot is supported by two bulk medication-packaging machines, which print an NDC/expiration date bar coded label using code 128. Once the robot was operational, we installed 22 ADCs on the units.

Repackaging Systems
The hospital pharmacy required a minor remodel to provide a footprint for the robot, support stations, packaging machines, and off-line inventory. The robot, its supporting equipment, and the cabinets were located within approximately 250 square feet. The storage area for the off-line inventory occupies 115 square feet of wall space and the robot’s bulk packaging stock requires just 15 cubic feet, significantly less area than the unit dose storage bins required previously.
Packaging machines were installed first, so we could gradually build an inventory of robot-compatible medications while depleting the unit dose inventory. In this manner, inventory was kept to a minimum, and nurses could become familiar with robot-ready packaging prior to the go-live. Two months into the transition to robot-ready medications, the pharmacy was packaging 800–1300 doses per day, Monday through Friday. Medications packaged for the robot were initially triple checked by two technicians and one pharmacist. Since BCMA implementation, medications for the robot are also verified by scanning the barcode.

Based on the prior year’s medication use, a three month packaged inventory of the top 360 medications that could be placed in the robot was ready prior to going live. The packaged inventory was reduced to a seven day on-line (in the robot) and off-line (outside the robot) supply as medication stock was reduced. Fast moving medications now have a three to four day supply, and packaging is done six days a week. The medications packaged and ordered daily are based on reports the system generates. Reports also identify medications that are rarely used and can be removed from the robot, as well as those medications whose frequency warrants adding them to the robot. The system can monitor usage of all formulary medications which are built in the pharmacy information system as unit dose medications, including IV push medications, tablets, capsules, patches, powders and liquids. Patient unit dose medications that are not in the robot are identified and dispensed by requesting a manual pick list, generated following the 24-hour fill, and hourly thereafter.

Orders for extemporaneously prepared bulk medications, and large and small volume IVs, are handled by the PIS. If an extemporaneously prepared medication is ordered frequently, and is compatible with robot packaging (i.e., small volume liquids >30cc, half tablets) it is added to the robot inventory. The dispense category is changed to unit dose, an “NDC” number is built, which the PIS, robot, and charge services identifies with that product. The robot currently holds 420 medications, and has room for about 70 more.

Medication Distribution
The 24-hour cart fill occurs daily from 12:30 to 2:30 AM. On average, another 60 minutes is needed for technicians to prepare and pharmacists to check the five to seven percent of medications that are needed for cart fill, but not dispensed by the robot. A real time patient admission, discharge and transfer report is generated and corrections are made prior to cart fill delivery.

The night pharmacist does a daily 10% random cart fill check. If there were no errors by the robot, the cart fill is delivered by technicians prior to the 9:00 AM  medication pass without further review by a pharmacist. The Washington State Board of Pharmacy allows all robot picked medications to be dispensed without pharmacist review as long as the daily 10% random cart fill check is error free. This includes all medications the robot picks for the rest of the day, such as first doses, changes, new admissions, etc. Medications from the robot are delivered to nurse servers in bar coded, patient specific envelopes. The bar code is recognized by the robot and support stations only. The bar coded label also includes the patient name and room number. When the technician places the envelope with current medications in the nurse server, any medications remaining in the server at that point (from a previous medication delivery, cart fill or otherwise) are placed in the envelope already in the server and returned to the pharmacy. Prior to implementing BCMA, the technicians would credit all returned medications by scanning the bar code on the envelope, and then the bar code on the returned medications. All credited medications are returned to the robot by placing them on the robot restock door, prior to running robot packaging and restock reports. Currently, with BCMA, none of the returned medications need to be credited, and can simply beadded to the robot. 

The robot picks all new orders four minutes after the pharmacist has completed the medication order entry process and signed off on the individual patient order. If the pharmacist informs the courier or technician that a new order is needed on the floor ASAP for a particular patient, that envelope can be delivered STAT or sent via the pneumatic tube to the floor right away. The pharmacist may opt to bypass the robot for a STAT order or missing medication and send the order to a printer next to the pharmacist work area, and then communicate directly to the technician when the label is retrieved. Good communication and follow through between the pharmacist, technician, and courier is essential (and challenging) for rapid turnaround time whether the medication is picked by the robot or prepared by the technician.

Managing System Downtime
The pharmacy experienced one extended robot downtime of ten hours. Since our PIS and robot can operate independently, if one is down, the other (most likely) is operating. When the robot was down, the information technology department generated paper MARs, which pharmacy used to complete the cart fill. The robot downtime was due to a bearing failure. We now keep
a spare bearing on hand in the pharmacy, and the director knows how to replace it.

Conversely, the robot and dispensing cabinets will operate during PIS downtime. While no new orders will cross the interface to the robot, the robot and unit based medication cabinets can dispense all existing orders. In the event of an unanticipated PIS downtime, a paper MAR can still be generated. Furthermore, medication information is stored hourly in a non-Cerner application.

Unit-Based Automatic Dispensing Cabinets
ADCs stock controlled substances in lock-lidded compartments. Frequently used non-narcotic pain medications, medications for nausea, common as-needed medications, and some emergency care medications are stocked in open matrix drawers. Routinely ordered controlled substances are dispensed from the ADCs. Routinely ordered medications for nausea and minor pain are dispensed by the pharmacy to the nurse servers.

Each machine has two to three empty lock-lidded compartments for narcotics and two to three empty open matrix slots for infrequently ordered medications. Restock reports are generated twice a day, filled by one technician and checked by another. Nurses can send restock requests to a pharmacy printer in the event of greater than anticipated use of a particular medication.

The pharmacy audits ADC narcotic discrepancies daily and spot audits narcotic dispensing from an ADC for waste and charting on the eMAR.

When an ADC malfunctions, pharmacy is the first contact as we are familiar with common cabinet problems and solutions. If pharmacy cannot bring the cabinet back on line, we will contact the biomedical engineering department. Biomed is contracted with McKesson to manage hardware replacement, and troubleshoot cabinet issues. In addition, they maintain a supply of replacement parts and are available 24 hours a day for repairs. Because most nursing units have more than one machine, many repairs can wait until the following day.

Prior to implementing BCMA, our ADCs charged on dispense. Currently, all ADCs on units with bedside scanning charge on administration. There have been some challenges with charging and charting when a patient is transferred to a BCMA unit from a non-BCMA unit and vice versa. Although this happens infrequently, some of the medications involved in patient transfers to and from the cardiac catheterization and angiography labs, for example, are expensive and need to be audited for charging and charting.

Nurse Servers
Our initial nurse server simply functioned as a chart holder/work platform for nurses, pharmacists and physicians and included a small medication storage area. With notable design changes to improve functionality, our nurse servers have since become larger to accommodate more medications. Our latest servers were designed by nursing and pharmacy and are large enough to accommodate several IV bags, a 2-liter bottle, and still have sufficient room for multiple medications, syringes and tubing. The servers are accessible from both outside and inside the patient room, allowing nurses to access all medications from inside the patient room, while pharmacy can restock the server without entering the patient room. Our nursing units with server access from inside patient rooms consistently record higher BCMA scanning percentages than those without in-room access. Because couriers, technicians and nurses access the servers frequently, we chose latches and locks that can be effortlessly operated to minimize wear and tear on fingers and wrists.

Staffing Changes
Throughout the implementation process, there was no change in pharmacy FTEs. The technician responsible for manual charging and record keeping transitioned to medication packaging as well as robot and ADC maintenance. The technicians who handled floor stock, narcotic delivery, and record keeping also provided support for ADC stocking, missing medication requests and triaging phone calls to the hospital pharmacy. In addition, several technicians were assigned to medication delivery for selected units to relieve some of the courier workload.

After implementing the robot, we were able to decentralize two additional pharmacists to perform order entry and clinical interventions on units that previously had been without unit pharmacists. The pharmacists on the floor were so well received by the nurses and hospitalists that we have increased unit pharmacists by 3.5 FTEs since 2004. Evergreen now has a decentralized day shift pharmacist on every nursing unit except ED and maternity, and an additional pharmacist on evenings Monday through Friday.

BCMA
Extensive bar coding of medications dispensed by the robot and unit medication cabinets combined with routinely scheduled medication delivery to nurse servers made the pharmacy transition to BCMA relatively painless. The pharmacy built bar codes for only 28 medications in order to bring the system up in December 2007. The emergency department, surgery and PACU, hospice, diagnostic imaging and the infusion center were the only non-BCMA units. Although it has been over a year since implementation of bedside scanning of medications, Evergreen is still dealing with this significant culture change for pharmacists, nurses, physicians and patients. Challenges such as extensive time required to prepare scanners for operation, nurses requiring both initial and refresher training on proper scanning technique, and substantial increases in phone calls to pharmacy rather than the help desk can lead to frustration and work-arounds.  Hospital pharmacy directors, managers and pharmacists who have been through this process will understand that at one year Evergreen has much to learn and implement before BCMA will function at its highest efficiency.

To implement this fundamental medication safety goal requires a significant investment of capital, time and vision. Committing to upfront investments in medication packaging and distribution systems will make for a much smoother transition to BCMA. 

Bob Blanchard, RPh, MBA, has served as the director of pharmacy at Evergreen Healthcare since 2002 and has been a hospital pharmacist for more than 25 years. His main area of interest is the utilization of technology in pharmacy.