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Automation frees time for prospective chart review
Integrating new automated dispensing technology with an already established computerized physician order-entry system (CPOE) has changed the way pharmacists work at El Camino Hospital, a community facility in Mountain View, CA. Freed from most dispensing duties, pharmacists now spend much of their time reviewing patient information before drugs are dispensed.
The hospital has seen a 250% increase in clinical interventions by pharmacists between 2002 and 2003. These interventions have resulted in a 500% increase in direct cost avoidance.
El Camino, located in the heart of Silicon Valley, was one of the first hospitals in the nation to begin using a CPOE tool in 1971. The system has a strong compliance rate with clinical users, says Mark Zielazinski, chief information officer. The pharmacists, as well as nurses and physicians, use this tool.
Drug dispensing tools, which had simple inventory dispensing capabilities, were added in the early 1990s. However, the hospital had the goal of moving toward bedside medication verification. The first step was the recent addition of new patient safety technologies. These technologies include a biometric drug dispensing system, a bedside drug bar-coding system, and an automated pharmaceutical and supply replenishment system that integrates with the CPOE system.
The hospital did three things simultaneously, Zielazinski says. It first upgraded the dispensing tools from being drawers of drugs to a patient profile tool. Next, it forced a complete medication verification process through the CPOE tool. "We were always verifying the orders, but now we are verifying them within a given time frame," he says. "We set our target to be 15 minutes. The mean, since setting the target, has been less than eight minutes, and the maximum time in the last quarter was 13 minutes."
Third, the hospital updated the process of how pharmacists interact with the system. "In the current quarter, they intervene at about four times the previous level of the same quarter last year," Zielazinski says.
Challenging implementation pays off
The implementation was at times challenging, but the updated system has been a positive change for the hospital pharmacists, according to Mei Poon, PharmD, director of pharmacy. With the exception of controlled substances, most of the medications had previously been dispensed directly from the pharmacy to the floors.
Now when the pharmacists receive the electronic orders from the physicians, the pharmacists have the medical profile history and patient notes available for review from the CPOE system. "After we had the interface, we were able to review all the medication orders prior to the nursing getting access to the medication," Poon says. This helps ensure the five rights before verifying the order: the right patient, the right medication, the right dose, the right route, and the right frequency.
The pharmacists’ verification of an order allows nurses on the unit to access and dispense the medications for the patients. The cubicles of the medication-dispensing machine will only open for the drugs listed for that particular patient. More than 85% of the drugs are now being dispensed on the unit, Poon says.
The automated pharmaceutical and supply replenishment system also largely bypasses the pharmacy. The system, for example, will tell a wholesaler exactly how many tablets it needs to deliver for a particular med station, she explains. The tablets will be delivered already prepackaged and bar-coded. When they arrive, pharmacy technicians simply refill the medication station on the unit. "Our goal is to maximize that process," Poon says. The technicians regularly make about three runs to the unit a day.
Number of errors reduced
This system has dramatically reduced the number of errors and the amount of "shopping" for a medication that had gone on in the past, Zielazinski says. "Nurses opened the drawer and had access to all the drugs that were in that particular drawer. Now the particular cubicle only opens for drugs listed for that patient and will not give out drugs until a pharmacist verifies the order." Nurses have the ability to override the system, but the overrides are tracked, and the number of overrides has decreased in the last two quarters.
New system allows prospective review
Dispensing the drugs on the unit also has allowed pharmacists to devote most of their time to prospective review, resulting in the 250% increase in clinical interventions. Many of the documented interventions address patients’ medication allergies, Poon says. "[With the new system,] we have on-line drug interaction and allergy cross-checking. We are able to catch a lot of the allergies/drug interaction potential problems and intervene ahead of time." Some of the interventions have prevented serious adverse effects, such as a warfarin (Coumadin) overdose.
In addition, some of the pharmacists have a window of time in which they do drug utilization review on specific high-risk drugs, such as warfarin or enoxaparin (Lovenox), Poon says. "They are able to devote the time just to do a focused review of patients who are on these high-risk drugs. They are able to correct dosing, make recommendations, and intervene when there is a problem."
The interventions, such as switching routes of administration or finding alternative therapies, have led to more cost-effective drug therapy — 500% in cost avoidance compared to 2002 levels. "That is just based on raw acquisition drug costs," Poon says. "It does not take into consideration the reduction of hospital days and length of stay."
The prospective chart review doesn’t take the place of having a pharmacist present on the unit, such as in a university setting, Poon says. But since El Camino does not have teams of physicians and residents going on patient rounds, the system is an efficient way of doing clinical review.
The automated dispensing system acts as a gatekeeper at the point of care, she explains. "Important information relevant to each patient’s medication regimen is available to front-line practitioners, since pharmacists are seeing the same data the physicians are seeing. This way, orders are reviewed before the medication is dispensed, rather than after the medication has been given to the patient at the bedside," Poon says. "The potential safety effects on patient care are profound."
Another benefit from the new system is that Poon has been able to expand the pharmacy hours without adding any FTEs (full-time equivalents). "We were able to restructure our workflow by becoming more staggered. We still are not open 24 hours, but we are close." The pharmacy is now only closed three hours a day, during the night shift.
El Camino plans to move ahead with improving its system in 2004. Next on the docket is a fixed patient station at the bedside. The hospital also plans to have medications bar-coded on a unit-dose basis.