By Ahmed Murtuza, BS, and Marc Summerfield, MS

Over the last 10 years, pharmacy- and hospital-based technological advancements have propelled dramatic shifts in pharmacists’ activities and focus. As health systems automate, pharmacists allocate more time to planning, supervisory functions, and clinical activities—including safety, quality, and therapeutics. Concurrently, technology is being used to help support these activities, as well as perform traditional dispensing functions. The University of Maryland Medical Center (UMMC) and its pharmacy department strive to exploit this shift. To that end, in 2005, UMMC installed sterile products robotic technology to automate sterile product preparation. The robot affords us the option to:

1. Convert patient-specific pre-mixed or extemporaneously prepared small volume parenterals to patient-specific syringes
2. Prepare bulk quantities of dose-standardized bulk syringes for niche use, such as in the OR
3. Convert manually prepared patient-specific syringes to robotic-prepared syringes

By converting the pre-mixed or extemporaneously prepared small volume parenterals to patient-specific syringes, we realized substantial cost savings.
Operational and Safety Improvements

Pediatric IV Syringes
Soon after installation of the robot, we shifted production of about one-third of the manually drawn patient-specific pediatric syringes to the robot. A ceiling was reached in the conversion because most doses constituted volumes that were in excess of the robot’s 12 mL syringe limit. Historically, the syringes were prepared in dilute concentrations, representing volumes between 1 mL and 60 mL. Although the dilution guidelines were reviewed annually, no major changes were made because they suited our needs at the time.

The desire to expand the number of robot-prepared pediatric doses compelled us to re-evaluate these dilutions and concentrate them to produce volumes within the robot’s range. A beneficial byproduct of concentrating the dilutions is the small volumes, which are more suited for fluid-restricted patients.

Eighty-five percent of our pediatric syringes are now robot produced, substantially improving efficiency and enhancing safety by minimizing the human element, ensuring aseptic preparation, and reducing the potential for error. Also, the shift in workload from manual preparation to robotic preparation permitted the reallocation of one FTE technician to other functions.

The remaining 15% of the pediatric doses, which are not robot-prepared, are either ordered infrequently or represent drugs that cannot be concentrated to accommodate the 12 mL syringe limit.

Addition of Workflow Managing Software
All manually-prepared syringes, such as the pediatric syringes and other manually prepared small and large volume parenterals, are now shunted to a software-based product that organizes the workflow in the IV admixture area and monitors progress of each batch.

Specifically, the software produces a bar-coded label for each dose at the time of preparation. Using a touch screen monitor, the technician is guided to select the correct vial and diluent. If the wrong item is scanned, the technician is not allowed to proceed until the correct item is selected and the bar code of the product matches the label’s bar code.

Photos are produced throughout the preparation process allowing the pharmacist to remotely verify (ensuring accuracy) and electronically “sign-off” (ensuring accountability). Illegible hand-scratched initials are now obsolete. The software is currently isolated to the IV admixture lab, but we plan to expand it to the satellite pharmacies as well.

OR IV Syringes
Preparing and labeling anesthesia IV medications has been a challenge. The Joint Commission requires that OR syringes be properly labeled. Anesthesia guidelines recommend that the OR syringe labels be color-coded by drug category to differentiate each therapeutic grouping and assist in proper selection. Traditionally, anesthesiologists are responsible for drawing and labeling the OR syringes, which introduces a human element and therefore the opportunity for error in both drawing and labeling. Using the robot to prepare and label the syringes has proven efficient and effective.

Symmetrical Every-Eight-Hour Batching
To expand our robot use, we are planning to implement every-eight-hour
(q8hour) symmetrical batches in the IV admixture lab. The increase in batch
frequency allows the IV lab to take on additional work (i.e., prepare doses that are now drawn in the satellites). This re-direction of doses exploits the advantages of our robot and the software we are using to produce manually prepared syringes. The satellites will still be responsible for limited first, stat, and emergent doses.

Batch Production of Standardized Doses
To increase batch production of bulk quantities of syringes, we are reviewing frequently-used drugs and doses to determine those that can be produced en masse by the robot if the drugs’ doses are standardized. For example, doses of cefazolin ordered at 995 mg or 1010 mg would be standardized to match the batch production of 1 g syringes. Alteplase (for catheter clearance), OR medications, and some anibiotics have already been dose standardized and are in production. In addition to the safety advantages, the robot’s ability to generate 300 syringes per hour compared with a manual rate of 100 per hour produces unparalleled efficiency.

Challenges
The transition to automation has created some challenges.  One such challenge is the limitation created by the 12 mL volume syringe limit. Sometimes, the data does not support concentrated solutions or other limitations prevail. For example, the concentration of vancomycin compatible with the robot’s syringe range is 1 g/10 mL. However, this concentration is unsuitable for good care because the concentration predisposes patients to “red man syndrome.” The maximum allowed is 5 mg/mL. To overcome this challenge, we plan to employ the robot to prepare 1 g/mL syringes, not for patient use, but to be subsequently added to a 250 ml bag to create the desired concentration. In other cases, multiple robot-prepared syringes (e.g., 3x10 mL) can be added to a single bag or bottle or syringe to create the desired dose (e.g., 30 mL).

Another challenge familiar in any manual-to-automation transition is meticulous training.  Adequate numbers of personnel must be trained not only in handling routine operations but also in troubleshooting predictable difficulties or complications.

Conclusion
Using a robot to prepare IV syringes yields significant efficiency and safety benefits.  Additionally, conversion of work from “humans to hardware” advances both patient care and personnel work satisfaction. An additional consideration is the positive cost savings.

Ahmed Murtuza received his BS in pharmacy from the Deccan School of Pharmacy, Hyderabad, India, and is currently enrolled in a non-traditional PharmD program at the University of Colorado at Denver and Health Sciences Center to enhance his knowledge, skills, and abilities. He is now a clinical pharmacist at the University of Maryland Medical Center having previously served as an IV admixture lab supervisor and a central production manager.

Marc Summerfield received a BS in pharmacy from the University of Connecticut School of Pharmacy and his MS in institutional pharmacy from the University of Maryland School of Pharmacy. He completed his pharmacy residency at The Johns Hopkins Hospital. He now serves as director of pharmacy at the University of Maryland Medical Center.

Digital Edition

PP&P is now available online in the exact layout and appearance of the print edition, and includes more interactive features, such as the ability to access websites and request information with the click of a mouse.  To view this article in the digital edition, CLICK HERE.