Hospital pharmacies are moving quickly to automate their temperature monitoring, given the efficiency gains and relatively low implementation costs for such systems. However, upon automating temperature monitoring, many facilities are confronted with the realization that the refrigerators being monitored are performing on a subpar level. At this point, the value of implementing medical grade refrigerators becomes apparent. These more sophisticated refrigerators maintain tighter temperature control, require fewer hours to maintain, and are more durable than non-medical grade refrigerators. In addition, once installed, medical grade refrigerators save on repair costs and time. 

Challenges in Refrigeration Storage 
One of the greatest benefits of medical grade refrigerators is their ability to maintain a tight temperature range, averting the large temperature fluctuations sometimes seen in regular refrigerators. A slight adjustment to a non-medical grade unit can send the temperature rising too high or falling too low. Following adjustments, staff often finds that the refrigerator never maintains proper temperature again. It is not unusual for ice, which acts as an insulator, to build up within these refrigerators, resulting in slow but steady temperature increases. Frequent defrosting is the only solution to this problem. Because a defrost cycle is built into the programming of medical grade refrigerators, ice buildup is never an issue. When large quantities of room temperature IV bags are delivered to a non-medical grade refrigerator, for example, it can take up to 12 hours for the temperature to return to the correct range. Medical grade refrigerators are built with sufficient insulation and powerful compressors that ensure the temperature will return to its setting quickly. 

Inadvertent adjustments to the thermostat dial in non-medical grade refrigerators are not uncommon when personnel are retrieving medications. These accidents then lead to out-of-range alerts. Medical grade refrigerators avoid this problem, as the temperature controls are located outside of the unit. In addition, multiple steps are required to adjust the controls, thus ensuring that only an authorized individual would be able to complete the process.

During busy periods on a unit, a refrigerator is opened and closed often to retrieve medications. Flimsy door seals in non-medical grade refrigerators can begin to malfunction as a result of constant use. As air leaks into the refrigerator through the seals, maintaining proper temperature becomes difficult. However, the stainless steel cabinet and heavy-duty seals of medical grade refrigerators are durable, have been designed for the hospital environment, and are able to withstand a high volume of use. 

When a non-medical grade refrigerator goes out of range, pharmacy technicians must respond to the alert. If pharmacy cannot adjust the refrigerator correctly, a maintenance technician is then called. Thus, staff spends an extraordinary amount of time monitoring, checking, adjusting, repairing, and documenting corrective actions. The use of medical grade refrigerators can save labor and time, since the correct temperature is maintained, precluding the need for pharmacy to respond to constant alerts. And since the components of medical grade refrigerators are more durable than non-medical grade refrigerators, maintenance receives fewer calls requesting repair.

When a malfunction occurs in a non-medical grade refrigerator, the entire unit must be removed and repaired. The medications it houses are transferred temporarily to another nursing unit’s refrigerator. The obvious problem with this scenario is that when two nursing units share the same refrigerator, overcrowding can ensue, leading to medication picking complications and potential errors. As medical grade refrigerators generally require less maintenance, this risk for medication error is minimized.



Evaluating the Options
Depending on the size of the facility and the budget allowance, there are many features to consider when deciding which refrigerator is the best fit. Factors that should be reviewed include:

• Stainless steel refrigerators/freezers. Stainless steel refrigerators are durable, with high quality hinges that can endure constant opening and closing.
• Door handles that latch or doors that close automatically. Once the door is closed, automatic latches attach to the refrigerator, eliminating the chance that the door is left ajar. Many out-of-range temperature alerts occur due to the door not being closed properly. 
• Narrow operating temperature ranges. The more narrow the refrigerator’s high/low temperature, the better. High quality refrigerators operate within a 1- to 2-degree swing. A non-medical grade refrigerator can have an operating temperature range up to 15°F.
• Sufficient interior capacity. A refrigerator used in a large unit must be able to hold numerous patient medication bins. Keep in mind that if the fan is located within the storage compartment, medications and bins cannot block the circulation of air in front of the fan.
• External thermostats. Temperature controllers for medical grade refrigerators are located on the exterior of the refrigerator. They can be programmed so that multiple steps are required to adjust the controls, thus ensuring that only authorized staff can make alterations. Accessibility to the thermostat also should be considered, as under-the-counter refrigerators with a thermostat located near the back of the unit are inconvenient to adjust.
• Air intake from the front. Air intake from the front of the refrigerator eliminates the need for circulation of air around the sides and back. For those nursing units with limited space, allowing sufficient space to permit breathing room all around the refrigerator can mean having to buy a smaller refrigerator than what the unit requires.
• Modular power pack. A power pack module contains the refrigeration system, including the compressor, fan, and evaporator, in a replaceable cartridge. If any refrigeration component malfunctions, it can easily be switched out for another power pack. The refrigerator does not need to be removed by maintenance to be repaired, and therefore medications do not need to be moved to another refrigerator.
• Integrated temperature monitoring. Temperature monitoring devices are included in some medical grade refrigerators, thus precluding the need to fund this purchase separately. However, the devices must be compatible with the wireless system used in the hospital.

Replacement Process
Teamwork and timing are critical to successfully switch to medical grade refrigerators. At the University of California Davis Medical Center, we first scheduled a meeting with pharmacy, maintenance, and engineering and did a walk-through of the staging area to determine how the refrigerators would be configured and what electrical sources would be used. After the new refrigerators were delivered to the staging area, engineering and pharmacy examined and tested them. As some were to be attached to automated dispensing cabinets (ADCs), the pharmacy technicians and the ADC vendor applied the necessary door brackets and hardware to enable use. At this point, maintenance helped pharmacy move the new refrigerators to the nursing units. Pharmacy should accompany maintenance throughout the move process to ensure the units are delivered to the correct locations, and then transfer the medications and appropriate labeling to the new refrigerators.

Implementation Challenges Overall, our implementation progressed smoothly. However, in hindsight, there are a few processes that, had they been in place, would have ensured a more efficient implementation. 

• Medical grade refrigerators are often heavier than regular refrigerators, and thus more difficult to move, so plan staffing accordingly. 
• Prior to attaching hardware, be sure engineering has thoroughly inspected and tested all units. Allow sufficient space around the refrigerators for pharmacy personnel to mount ADC hardware and for engineering to attach equipment tags.
• A pharmacist must be present during the installation process, both to ensure quality control and to transfer the medications into the new units. 
• Inspect new refrigerators immediately upon delivery for damage and again after they have been moved from receiving to the staging area. Report any damage to the manufacturer immediately.

Conclusion
Implementing medical grade refrigerators requires cooperation and teamwork from multiple departments, but the medication safety benefits and lower number of service calls make the project well worth the effort. At our facility, the new medical grade refrigerators have brought about increased peace of mind, as pharmacy no longer needs to respond to numerous out-of-range alerts or worry about the safety of medications stored at improper temperatures.

Sylvia Wong, PharmD, is the medication security pharmacist at the University of California Davis Medical Center in Sacramento. She received her degree from the University of the Pacific School of Pharmacy in Stockton, California. Sylvia’s professional interests include finding creative ways of resolving regulatory issues in the hospital pharmacy environment.