As the third largest medical center in the St. Louis metropolitan area, St. Anthony’s 767-bed facility provides health services to over 225000 patients. The overall pharmacy operation at St. Anthony’s is centralized with satellite services in our OR. During day shifts, we designate three decentralized pharmacists; one each to the IV room, the medication vault, and the OR satellite pharmacy, to complement the three or four centralized pharmacists. Also, we have approximately 18 of our 23 full-time technicians on duty with six assigned to specific assignments—buyer, stock, narcotics, OR, automated dispensing cabinets (ADCs), and charge. For our evening shifts, we station five pharmacists in the central pharmacy and have two pharmacists assigned to other areas of the facility. We store about 80% of all unit medications in automated dispensing cabinets on the floors and have eMAR and BPOC systems in place.

Selection Criteria and Cost Justification
Like many hospitals, we try to purchase as many bar-coded unit dose items as possible directly from the manufacturer, and these products constitute about 85% to 90% of our medication acquisition. This fluctuation is due to shortages, outages, and recalls that can occur on a daily basis. Because of these common disruptions, we realized a need to be able to repackage not only solid dose medications, but liquid doses as well.

Making the decision to purchase a liquid unit dose packaging machine was influenced by multiple departments. The main purchasing criterion was compatibility with our pharmacy information system (PIS), as we needed the technology to generate labels that contained information and bar codes readable by our PIS. During our research into the various options, we also considered overall cost, machine size, ease-of-use, multi-size packaging capability, and the quality and efficiency of the bar-coded labels produced by the machine. Ultimately, cost was the major determining factor with ease-of-use also making an impact.

Justifying the cost of the machine to administration was surprisingly easy. Several staff members—including the pharmacy director, operations manager, and PIS- and ADC-assigned pharmacists—presented in favor of the machine, citing increased efficiency in bed-side scanning, reduced medication errors, consolidation of medication bar codes, and lower overall cost.

Implementation and Cost Savings
As part of our implementation, we decided to develop our own user manual that takes the technician through the entire process, step by step, using images and screen shots for support. Our goal is to establish at least two expert users who can train the remaining technicians, as well as new hires, on how to use the machine. Installation and programming took just one day, and a vendor representative was able to come on-site, train our primary techs, and provide a flow chart for using the machine. The only workflow change we had to make was to allow for the time necessary to package liquid medications.

Post-implementation, we have begun to realize not only a net cost savings of around $0.05 per dose—a number we expect to increase once the original investment has been reconciled—but also other, unforeseen advantages. The standardized packaging used by the machine produces highly accurate doses that are easier to stock in our ADCs than syringes or bulk bottles that previously needed to be poured out for administration. This has led to increased satisfaction from our nursing staff, as they no longer need to take both the dose and the bulk bottle into a patient room to scan at the bedside.

Conclusion
Whether you are considering the purchase of a liquid unit dose packager to supplement an existing unit dose medication process, or to function as a primary packaging system, it is essential to evaluate as many vendors as possible, looking at not just cost, but also intuitiveness and ease-of-use. A complicated piece of equipment will always incline the user towards procrastination, and it increases the risk of sloppy packaging.

When training staff, do so in a one-on-one situation or with small groups. Staff need to know that the processes they are undertaking with a piece of technology like this are vital, and driving that point home is easier when you are working in an individualized setting. Also, we found it helpful to develop our own user’s manual. Though the training and information supplied by our vendor was thorough, we felt it was well augmented with a step-by-step manual unique to our operation.

Going forward, we have decided to include proficiency with both our solid and liquid unit dose packaging machines as part of our yearly core competence requirements for technicians and pharmacy students. It will also become a standard part of all new hire training. Ultimately, control over the packaging process combined with the ability to develop our own bar codes has made the use of a tabletop liquid unit dose packager a safe, efficient, and timely solution to our liquid medication needs.

Glenna L. Vandergrift, CPhT, is a pharmacy buyer at St. Anthony’s Medical Center in St. Louis, Missouri.