Inpatient Pharmacy Workflow Processes and Daily Routine

1. Inpatient Pharmacy Workflow Processes and Daily Routine June 2011

2. Course Objectives • Identify at least two steps involved in developing a strategic plan for improving a health system's process for preparing Compounded Sterile Products (CSPs). • Discuss the need for patient safety-related improvements in the process for preparing CSPs in many health-system pharmacy departments • Leverage HIT, data management, and workflow to strive toward the patient-centered medical care model

3. Course Objectives • Configure Inpatient Pharmacy v5.0 site parameters for IV and UD menus • Compare & contrast Inpatient Pharmacy IV and UD reports • Use Inpatient menu options to perform routine daily IV and UD tasks • Identify good practices for managing workload using Inpatient Pharmacy v5.0

4. Overview • Daily inpatient pharmacy workload: • IV Package routine tasks: • - Printing reports/lists, Printing Labels, Manufacturing of IV’s, etc. • Unit Dose Package routine tasks: • - Printing pick list, cart-fill (if no Pyxis), entering doses dispensed, etc.

5. IV Menu Site Parameter Configuration • IV Menu > Supervisor Option > Site Parameter Edit • Allows configuration of defaults: • Name(s) of IV Room(s) • Label specifications • Duration of orders for various IV types: • Automatic stop dates different from the defaults may be entered for individual additives in drug file • Coverage times (i.e., 24 hour batch time frame) • Devices for output (reports, labels)

6. Daily Routine for IV Package • Print Active Order List (optional): • Review, update orders as needed • Print Ward List • Print Manufacturing List • Print Scheduled Labels • Prepare IV’s, check, deliver to ward

7. Daily IV Workload – Active Order List • Prints list of all currently active IV orders: • Sorted by ward • Can be printed at any time • Variety of uses as a worksheet: • Take to ward and check IV admixtures for current rates, # of bags needed. • Use to review IV antibiotics against culture results. • Compare to MAR to see if nurses changed any administration times.

8. Daily IV Workload – Ward List • Ward List prints all active orders: • Sorted by ward • Shows # of bags due for 24 hour coverage • First step in sequence for daily IV batch: • Ward List, then Manufacturing List, then Scheduled Labels (always in this order) • Ward List is used by pharmacist to check each bag/label prior to delivery to ward.

9. Daily IV Workload – Manufacturing List • Prints all active orders: • Lists all admixtures first: • Sorted by base solution, with totals • Lists all piggybacks next: • Sorted by additive and strength, with totals • Used by technicians to assemble needed bags & additives, record lot numbers. • After admixture, technician separates IVs by ward for checking by pharmacist.

10. Daily IV Workload – Scheduled Labels • Prints labels for all IVs due for 24 hour batch: • Labels print in same order as manufacturer list (batched by drug/dose). • Good practices: • Check printer before sending print job: • Ensure labels correctly aligned. • Ensure adequate # of labels. • Watch labels to ensure they don’t curl back.

11. Other IV Menu options: Reprint Scheduled Labels • Shouldn’t need to use this often: • Especially if you follow good practices and watch the printer during scheduled label print job • If labels jam partway through print job or run out: • Can print selected range of labels • From last usable label to end, or to next usable label

12. Other IV Menu Options:Individual Labels • Print labels for one patient • Program gives two choices: • Reprint labels • Print New Labels • Program asks if the labels should “count as daily usage?” • No for reprints • Yes for new labels

13. Other IV Menu Options: Suspense Functions • Allows labels to be suspended from printing with the batch • Labels can later be released for printing • Possible uses: • High cost items • Items that may be discontinued • Items unlikely to be re-usable: • Neonatal syringes, oddball admixtures

14. Other IV Menu Options: Returns & Destroyed Menu • Used when IVs or IV labels need to be credited • Labels that were printed but never mixed: • Use Cancelled option • Labels that were printed and mixed but can be re-used for another patient: • Use Recycled option • Labels that were printed and mixed and cannot be used for another patient: • Use Destroyed option

15. Other IV Menu Options: Renewal List & Inpatient Stop Order Notices • Reports that print orders that will expire in a selected time frame (e.g. next 24 hours): • Renewal List prints only IV orders. • Inpatient Stop Order Notices prints IV orders, U/D orders, or both. • If your site has automatic stop dates: • Use report to notify providers. • Provider must decide whether to renew or let order expire.

16. Automatic Stop Orders (ASO’s) • Are ASO’s necessary? Helpful? • Good practice suggestion: • Eliminate ASO’s in policy for most drugs. • Configure RPMS parameters to maximum allowable stop date. • Exceptions to consider: ketorolac, narcotics? • For the exceptions, can set shorter ASO under orderable item file or additive file.

17. UD Menu Site Parameter Configuration • Unit Dose Menu > Supervisor Option > Inpatient Ward Parameters Edit • Allows configuration of defaults: • Automatic stop dates for UD orders • Start time calculation: • Now, Next Scheduled or Closest Scheduled • Automatic printing of MAR labels • Default print devices

18. Daily Routine Workload for Unit Dose (UD) Package • Print Pick List* • Perform cart fill if no ADM (Pyxis/Omnicell) • Enter Units Dispensed* • Report Returns* * Process differs depending on whether or not your site has Inpatient ADMs with Profiling and Interface

19. Daily UD Workload:Printing Pick List • Pick list prints all active UD orders: • Sorted by Ward, then Room/Bed • Shows doses needed for next 24 hours • Used as worksheet to fill UD med carts • If Pyxis or Omnicell, do not need to actually print: • Still need to RUN Pick List, but can print to screen or enter “^”

20. Pick List - with Cart Fill • Number of units dispensed is recorded on line. • Items marked Ward Stock will show WS as units needed. • Orders that are schedule type R (Fill on Request) will show zero as units needed.

21. Daily UD Workload:Enter Units Dispensed • Allows pharmacist to enter into RPMS the doses actually dispensed for each med: • Tip: when appropriate, simply Enter at prompt to accept that units dispensed = units needed • Optional: view only prn med orders: • For schedule types other than prn, program assumes units dispensed = units needed • Program jumps past items listed as WS: • When finished, you are prompted: • “May I file this pick list away”?

22. Daily UD Workload: Enter Units Dispensed (Sites with ADM) • Bypassing Enter Units Dispensed entry: • At first patient, enter “^^^” to skip to the end. • Program automatically accepts units needed equals units dispensed for each item. • Caution - if any item is not marked as WS the program will double count: • Pick List doses plus doses removed from ADM • Good Practice – do the complete Enter Units Dispensed, at least periodically.

23. Other UD Menu Options:EXtra Units Dispensed • Used to enter extra unit doses dispensed: • e.g., lost, dropped • Fill on Request items (e.g. new tube of cream) • For sites with ADM (Pyxis/Omnicell): • Use this option if item not stocked in ADM. • If item comes out of ADM and nurse removes extra dose, it is recorded automatically.

24. Other UD Menu Options:Report Returns • Used to credit unit dose meds: • When patient is discharged • When order is discontinued • If your site has ADM with interface: • Meds returned to ADM by the nurse will be subtracted in RPMS automatically • Still may need to use this option: • e.g., Albuterol inhaler prn - dispensed but never opened/used

25. Summary • Inpatient Package Daily Routine Tasks: • IV Menu: • Ward List, Mfg List, Scheduled Labels • Other options as needed • UD Menu: • Pick List, +/- Cart Fill, Enter Units Dispensed • Other options as needed