Pharmacy Purchasing & Products: Why did you decide to outsource your TPNs?

Harriet Catania: In 2007 we were looking for the best way to meet USP requirements without undertaking a complete remodeling of the cleanroom. We did not have money in the capital budget that year for facility development or new equipment and it would have taken at least 18 months to get the necessary capital allocated for these expenses. These financial hurdles, in addition to the time required to remodel a cleanroom, made outsourcing an alternative worth exploring. We eventually decided this route was the easiest, quickest, and most effective option to meeting standards in a timely manner, and we have been outsourcing all of our TPNs for the past two years.

On top of helping us better comply with , outsourcing allowed us to redirect technician and pharmacist time—previously focused on preparing TPNs and batched solutions—to upcoming automation expansion projects.

PP&P: How can outsourcing TPNs streamline pharmacy operations?

HC: Deciding to outsource TPNs provides an opportunity to standardize procedures and delivery times for TPNs if these are not already in place. If your facility does not have protocols allowing pharmacists to manage TPN ordering, outsourcing also presents an opportunity to open a dialogue with the physicians at your hospital about the benefits of having pharmacy more involved in the TPN ordering process.

PP&P: What was the biggest challenge to outsourcing your TPNs?

HC: Our greatest challenge was adjusting the workflow to accommodate the new timing of the TPN ordering that we had to institute to manage the delivery of  TPN.
At St. Joseph’s Medical Center, our pharmacists have the authority to order TPNs under protocol, and most physicians use this pharmacy service. However, there are still a few physicians that prefer to do their own ordering. Prior to outsourcing, TPNs could be ordered by pharmacists and physicians at any point during the day; they were prepared by pharmacy in the afternoon and were hung at 6:00 PM. In order to receive our TPNs from the vendor in time for the scheduled evening hangs, all the orders had to be placed by 12:30 PM so they could then be transmitted to the outsourced vendor by 1:00 PM, processed and delivered back to us by 8:00 PM to make the 9:00 PM hang time.

To meet the new order deadline, the pharmacists assigned to TPN service had to start rounds at 9:30 AM, which meant they were leaving the central pharmacy during what had always been a peak time for orders. As we gained experience with the process, we found it necessary to adjust our pharmacist schedules and shifts to provide the needed coverage in the mornings.

It also was a challenge to get physicians who did not use the pharmacy TPN service to adjust the time they rounded and wrote TPN orders. To get the physicians on board, we started communicating the process change and rationale several months before we made the change to outsourcing.

After the new ordering procedures went into effect, the pharmacists providing our TPN service worked very closely with the physicians ordering TPNs during the morning to ensure the orders were submitted on time. This was fairly easy to accomplish.

PP&P: How did you choose your outsourced compounding vendor?

HC: Our proximity to the vendor’s compounding site was a strong determinant; the vendor is located 70 miles from our medical center. The ability to consistently meet our daily delivery schedule was a critical factor as well. At the time, other hospitals in our health system had contracts with this provider and we were familiar with them, but we were the first hospital in our system in Northern California to outsource TPNs. We conducted a site visit to review the facility and the quality control measures in place. To ensure the continuous quality of our outsourced products, we receive quality control reports on a quarterly basis.

PP&P: Besides TPNs, what other products do you outsource?

HC: Currently we outsource high-use antibiotics not available as premixed solutions, as well as oxytocin solutions. Within the last year we have begun outsourcing PCA syringes and some narcotics, such as epidurals, to a second oursourcer, as our original vendor did not handle controlled substances.

Outsourcing helps ensure the sterility of these products as there are certain quality control measures that are done by the outsourcing company that we do not do in-house (i.e., extensive, weekly employee practice testing and weekly particle counts in each hood). Items that are on the shelf for a longer period of time (e.g., batched items) are at an increased risk for contamination, so outsourcing these items helps mitigate this risk.

PP&P: Where do you see the future of outsourced compounding services in pharmacy?

HC: Given the convenience of outsourcing, I only see pharmacy’s use of outsourced compounding vendors increasing in the future, particularly for smaller facilities that might not be able to easily meet requirements without substantial upgrades to their cleanroom and related equipment. For larger facilities that are challenged by staffing issues or increasing compounding volume, it is much easier to use an outsourced compounding vendor as opposed to hiring and training additional staff.

Harriet Catania, PharmD, FASHP, is director of pharmacy at St. Joseph’s Medical Center in Stockton, California. Harriet is responsible for all pharmacy services there, including inpatient pharmacy, a home infusion service, two retail pharmacies, and a disease management clinic. She is program director for the ASHP PGY1 Residency and an adjunct professor at the University of the Pacific School of Pharmacy.

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