Mt. Carmel Health System is a four-hospital system comprising Mt. Carmel St. Ann’s (MCSA), Mt. Carmel New Albany (MCNA), Mt. Carmel West (MCW), and Mt. Carmel East (MCE), all serving the greater Columbus, Ohio area. MCE is a 330-bed tertiary care hospital that runs a very high census, has about 96,000 emergency department visits per year, and provides inpatient services in the areas of cardiology, open-heart surgery, NICU, multiple intensive care units, neurosciences, and other medical and surgical specialties. Considering the size and scope of the hospital’s services, a 24-hour pharmacy is a necessity.

The pharmacy can be described as a hybrid model consisting of centralized distribution using a McKesson robot with limited Pyxis cabinets for pain medications and other critical prn medications. We also have six staffed satellite pharmacies spread over three buildings on the day shift, with three of the satellites open on evenings, and total centralization on third shift. The satellites function as order entry workstations, with orders being scanned via Pyxis Connect. In this staffing model, the pharmacists perform both order entry and clinical monitoring from the respective satellites. The total pharmacy staff consists of 27 FTE patient care pharmacists, 20 FTE technicians, two managers, a purchasing pharmacist, interns, a pharmacist analyst, and a director.

In-House Repackaging
About eight years ago, MCE was the first hospital in the system to install a pharmacy robot. At that time, the contract also provided for “in-house outsourcing” of the bar code packaging service. After utilizing this model for several years with good results, it became apparent that one of the disadvantages of this service was having to interrupt a pharmacist from his or her workflow to check the packaging technicians’ production. There was never a good time to do this, and it was difficult to keep it a priority in the pharmacist’s daily activities. There was always the fear that a product might find its way into distribution before being checked. As true outsourced packaging was available, and given the fact that we are operating in an environment of productivity monitoring, and FTE reductions, the total outsourcing approach became attractive.

Transition to Outsourcing
Of the four Mt. Carmel hospitals, MCW was the first to transition to a total outsourcing option with Shamrock Medical Solutions. Shamrock receives the medications directly from the wholesaler, packages them in the designated robot-ready bar coded form, and ships to MCW with a 24-48 hour turnaround. MCE is transitioning an increasing number of medications to Shamrock, particularly those items that require large runs or are time consuming to package such as fast movers or items like prefilled syringes. In addition, MCSA is using Shamrock more frequently, sending the company products such as narcotics, oral liquids, oral syringes, and contrast agents.

The fact that Shamrock Medical Solutions has a facility in the Columbus area has given us an additional advantage of quicker turnaround time, and thus reduced our need to adjust inventory to any significant degree. Shamrock is an FDA-registered repackager that utilizes contemporary software and systems to provide safe, well-controlled, quality products. We continue to increase our use of its services and accrue the benefit of added safety and efficiency.

Reporting and Oversight
The process of tracking and accounting for the outsourced products has proven to be efficient as well. Our wholesaler invoices us at contract pricing for items sent directly to Shamrock. Shamrock, in turn, provides an itemized invoice with each shipment. They also provide a history of our utilization to assist us with inventory control, and to help reduce or eliminate waste associated with expired drugs. As an FDA-registered site, Shamrock provides us with all appropriate product recall information and acts on that information as dictated.

Adapting Systems to an Outsource Provider
Shamrock has an extensive bar code label library with the ability to meet customer needs for a scannable label. We review the label with Shamrock before any new product is packaged. Using Shamrock has eliminated the need for one of our pharmacists, usually on second shift, to step out of the workflow and check the day’s production of packaged product. Our buyer coordinates the purchasing and packaging process by his ordering patterns, and can adjust inventory levels if necessary.

We have maintained the manual application of bar codes to products such as metered dose inhalers and Blistex. Shamrock has provided MCW with a packaging machine for those small batch runs that could serve as a back up to the primary service in case of an emergency.

Financial Impact
When a hospital commits to bringing a robot into the pharmacy or to point-of-care scanning of medications, it is committing the pharmacy to providing all dosage forms of medications in a readable bar code format. This comes with an increased up-front expenditure for the packaging costs. Some of the cost of this packaging can be controlled by purchasing the medications in bulk, and then packaging them in the robot ready form, thus eliminating the added cost from the manufacturer for a bar code ready product. Each product needs to be analyzed to determine cost effectiveness.

Shamrock offers tiered pricing based on dosage forms, production-run sizes, and hospital or system volume commitments. This gives Mt. Carmel Health System the incentive to increase our use of Shamrock’s services to reduce costs. In addition, we are receiving our medications from an FDA-registered site in packages that have been through a quality-controlled process and are ready for dispensing. This enhances our mission of patient safety and quality, and reduces the risk of medication errors. We have always had the support of the hospital administration when budgeting for this patient safety initiative.

Conclusion                                                                                                                    Outsourced repackaging is an option that all hospital pharmacies supporting a medication point-of-care scanning process should consider. It is important to define your needs and carry out due diligence when considering an outsource option. Send out a request for information (RFI) or request for proposal (RFP) to each vendor and consider the following information: FDA registration, description of the repackaging processes, quality control steps, samples of packaging and labeling, bar code capabilities, and a list of customer references. Most important, take a tour of the facility if possible. We were able to do these things with Shamrock, and our questions were answered completely. I realize that pharmacy directors have options when it comes to achieving a bar coded product; one philosophy is, “leave it to the professionals.”

David L. Bystrom, PharmD, MBA, is director of pharmacy at Mt. Carmel East hospital in Columbus, Ohio. David received his BS in pharmacy at Oregon State University, his PharmD at the University of Michigan, and also completed his hospital pharmacy residency at the University of Michigan. David received his MBA from Capital University and is an adjunct faculty member of Ohio State University’s College of Pharmacy, as well as an instructor in the pharmacy technician program at Columbus State Community College.