An article reviewing the implementation of automated medication dispensing system in the Emergency Department of La Mancha-Centro General Hospital of Alcázar de San Juan, Spain
Ángel Atanasio Rincón
Supervisor of Pharmacy Department
Beatriz López Pérez
Mª Carmen Conde García
La Mancha-Centro General Hospital of Alcázar de San Juan
Antonio Atanasio Rincón
Villarubia de los Ojos
Mª llanos López Pérez
Foundation for social and labour integration of the mentally disabled (FISLEM)
Elena Ramírez Ruiz
Student of Translation and Interpretation
Autonomous University of Madrid
The Emergency Department of La Mancha-Centro General Hospital of Alcázar de San Juan (Ciudad Real, Spain), listed as a large general hospital according to the Top 20 Hospitals classification, contains four parts: boxes; specialties; paediatrics; and observation. An average of 4,617 patients attend the hospital every month.
This unit has at its disposal a drug stock, which is reordered by the supervisor of the Pharmacy Department twice a week, and placed by the department’s nursing assistant. In case something out of the ordinary is needed it is considered urgent and is ordered by means of a special prescription. This order is received in the Pharmacy Department, prepared by nursing assistants and distributed by an orderly. Furthermore, because the unit works on demand, serving minimum hospital-stay-patients and because of its drug stock characteristics, the staff has easy access to medicines.
After the implementation of the Automated Drug Dispensing System (SADME Pyxis), all the daily demand and replacement work is carried out by the pharmacy staff. The computer system prints a daily request for the required drugs below an established minimum stock and the pharmacy staff prepare, provide and place these at the SADME Pyxis stations, increasing the workload to the Pharmacy Department. This is useful for drug use control. After collecting information from the Admission Department, the system identifies the patient and a course of treatment is assigned once it is prescribed by the physician. The withdrawal of drugs from SADME Pyxis is done in a personalised way, through fingerprint recognition or a personal code, according to each Emergency Department worker profile.
To evaluate the impact on workload and cost after the implementation of SADME Pyxis in the Emergency Department.
Materials and methods
The implementation of three SADME Pyxis was carried out in June 2008 in the Emergency Department in the boxes, specialties and observation areas. After that, a prospective and observational study was carried out, analysing the following variables: workload distribution; urgent prescription requests; and cost per emergency patient attended.
1. There was a workload decrease of 70 minutes per week in the Emergency Department, because there was no need to apply for a request and place drugs in the stock, although the workload in the Pharmacy Department increased from 87.8 to 980 minutes per week. According to the previously established minimum and maximum stock, the system prints a request that is prepared by the nursing assistant for the 3 SADME Pyxis in an average duration of 40 minutes per day. After that, a nurse and the nursing assistant who prepared the request distribute and place it in its own box within the three SADME Pyxis. This is in order to suspend the automated system for the minimum possible time in an average duration of 50 minutes per day (the total time is 100 minutes per day).
2. Drug requests are analysed by means of urgent prescriptions during one month before and one month after the three SADME Pyxis implementation. The result was a decrease of 45% (from 161 to 88 per month). This information shows a time saving for the Emergency Department nursing staff, as they do not have to look for the drugs they need.
3. The real decrease in annual consumption in the Emergency Department was 76%, from €337,628.99 (May 2007 – April 2008) to €81,180.64 (September 2008 – August 2009). The months around the implementation month were not included, in order to avoid problems that could be caused by possible returns of accumulated drugs of the previous stock system and extra replacements until the SADME Pyxis normalised the operation.
The cost per emergency patient attended has also shown a decrease of 76%, from €6.08 before the implementation to €1.46 after the implementation – 55,492 patients attended during the study period before the implementation, whereas 55,341 patients arrived in the Emergency Department during the post-implementation period.
SADME Pyxis is a useful tool in drug use control. Its operation and drugs distribution helps to reduce treatment mistakes and improve dispensing security. The accumulation in drug stocks and the resulting problems such as poor preservation of drugs, breakages, expirations and so on, cease to exist. The Pharmacy Department controls the drugs’ expiry date, withdrawal and distribution by means of a standardised procedure.
A clear decrease in pharmacological costs in the Emergency Department has been seen due to the decrease in drugs, storage, control over attending patients and controlled access for permitted staff, by means of fingerprint recognition with restrictions depending on professional activity. Thus, it becomes a useful tool for financial management.
One of the most important characteristics of SADME Pyxis is the amount of information it provides, which helps to improve prescription quality regarding security, efficacy and cost. This information should be more deeply studied in order to analyse the quality and effectiveness of drugs, use.
This system involves the advantage of reducing bureaucracy for the Emergency Department nursing staff and makes it possible to dedicate more time to assistance functions. However, it entails an increase in workload for the Pharmacy Department in the implementation (minimum and maximum stock elaboration, agreeing pharmaceutical variability, computer connection, user monitoring) and the daily maintenance of SADME Pyxis (requests preparation, replacement and drugs control, checking the previous day’s activity, such as histories and narcotics). These systems provide an information analysis that entails a time expense that the Pharmacy Department has to face in this kind of process.
An important drawback in the SADME Pyxis implementation and development is the rejection and distrust on the part of the Emergency Department, besides the high cost. We considered the latter to be justifiable, because of the saving in drugs, consumption and the usefulness of the information created.
According to the study, we have observed a rejection of the implementation of the automated system on the staff’s part, so that the system integration needs a change in work culture. In the psychological field, we have introduced elements that the workers need to face in order to change rules, behaviours, ways of thinking and established habits. In psychology, these routines are called resistance to change. This change means that workers have to unlearn previous rules and learn new rules, so this is not an easy process.
The reasons for this resistance to change can be classified into knowledge areas, skill development and motivation. The changes are a challenge, and it is important to:
- Present the new system in the maximum possible detail.
- Be able to differentiate between urgent and not urgent action.
- Rely on a strong management group.
- Make sure everybody knows the benefits of change.
- Encourage staff participation and the creation of teamwork.
- Appreciate correct courses of action, despite isolated mistakes. Make people learn by experience.
- Establish a monitoring system.
- Show achievements to encourage staff.
The perception of change moves through different phases, from apprehension when facing the prospect of change, to assent when the change has been implemented (moving through refusal, fury, excuses and acceptance).
We obtained an interaction between the Pharmacy and Emergency departments, resulting in an improvement in the service and a beneficial integration in the multidisciplinary team for problem-solving related to treatment and future projects.
For the reasons cited above, we consider that an investment in human resources and materials is justified.
Workload is increased in the Pharmacy Department and reduced in the Emergency Department in the execution and placing of the drug order and requests for urgent prescriptions. Thus, it makes it possible to spend more time assisting patients. Drug cost in the Emergency Department is reduced by 76% after the implementation of SADME Pyxis, so an investment in human resources and materials would be justified.