Laurence A Goldberg, FRPharmS
Editorial Consultant, Hospital Pharmacy Europe
Throughout Europe, government departments, professional bodies and pharmacy organisations have recognised that the way forward for hospital pharmacy practice is through automation of some basic pharmacy processes.
In some countries, this has been set out in strategic plans for pharmacy services. In the UK, for example, an Audit Commission report – A spoonful of Sugar: medicines management in NHS hospitals, published in 2001 – recommended that pharmacy staff could be released for additional clinical duties through the introduction of automated dispensing systems.
The report went on to recommend that the Department of Health should set aside funds to support the purchase of robots for all large acute hospitals in light of the improvements that they could offer.
In Spain, the Spanish Society of Hospital Pharmacists has drawn up a vision document describing how hospital pharmacy services should look in 2020. The objective of this ‘2020 project’ is to maximise the safe and appropriate use of drugs. A key strategy for doing this is to incorporate technological advances, including robotics, to improve the safety and overall quality of pharmacy services.
Many publications have described the use of electronic ward cabinets in The Netherlands, where unit dose distribution systems are well established. Automated packaging of unit doses is now making the process more efficient. In addition, the newer robots are compliant with good manufacturing practice (GMP). Final product identification is now also a possibility.
In the Nordic countries, the first generation of unit dose-packing robots was introduced about 20 years ago and some of these robots are still in use today, although newer, more efficient models have superseded many of these.
Rapidly developing technology
Over the next few years, new and rapidly developing technology will change the face of pharmacy services as we know them today. The drive for this will come from both within the pharmacy profession and from outside. A climate created by a need to improve patient safety, rising consumer expectations, rising healthcare costs and a shortage of nurses and pharmacists in our hospitals will speed up this process.
Against this background, there has already been steady progress in the development of new technology, resulting in an increase in the number of tasks that can now be automated. In addition, today’s machines can handle these tasks quicker and more accurately than human beings. Pharmacists are finding that automated medicines management systems, once feared as a threat to job security, are now providing opportunities to change practices by moving staff away from manual drug distribution towards direct patient care. The technology is enabling pharmacists to re-engineer drug distribution, freeing up time to support their clinical role. The technology also offers enhanced record-keeping, improved patient education, more efficient monitoring and greater patient compliance with prescribed medicines.
Today’s automated technology can order, store, package and dispense medicines in a busy pharmacy. These systems are increasing productivity, controlling inventory, decreasing medication errors and enhancing security in all pharmacy settings.
Two types of automation are being used across Europe: decentralised cabinets and centralised robots, each offering many opportunities for improving the efficiency of the supply chain and reducing medication errors.
Decentralised systems are modular electronic cabinets and trolleys (carts) that store and dispense drugs and other medical supplies in locations outside the central pharmacy, such as on the wards. They can also work in tandem with centralised pharmacy systems to maintain a seamless supply chain and control inventory.
From the ward perspective, a major benefit is to have medications available as soon as they are prescribed. These systems can hold either original packs or unit doses and the software can be preloaded with patients’ prescription details and other relevant information. Some cabinets and trolleys identify the exact cell from which the dose must be taken.
Because regular prescriptions are entered into the patient database, an electronic medication administration record can be generated. These cabinets can also be used to store narcotics and other controlled drugs and an electronic stock balance can be maintained at all times. While decentralised machines are used primarily for point-of-care drug supply, centralised systems are located in the pharmacy for the purpose of ordering, maintaining inventory, stocking and dispensing patients’ medications.
Automating drug distribution from the pharmacy offers many advantages:
- Developing clinical services by re-deploying staff
- Reducing inpatient waiting time in an ambulatory care setting
- Improving patient safety by reducing medication errors
- Improving inventory control
- Interfacing with computerised prescribing and medicines administration systems
- Outsourcing the supply and distribution in small hospitals and clinics.
When discussing the merits of automation, pharmacists also raise issues that they perceive as barriers to taking the next step. In most cases, their fears turn out to be groundless and can be allayed by site visits and discussions with colleagues who have been early implementers of pharmacy automation.
Examples of barriers perceived by pharmacists include:
- High capital cost – this can be overcome by preparing a good business case for automation
- No back-up – back-up systems can be built in to meet most eventualities
- Fears of new technology – not found to be the case in practice
- Insufficient workload to justify the expense – modern robots can be multifunctional
- Pack variation – robots can handle patient packs, bottles and unit doses
- Space requirements – robots are space-efficient and have a small footprint compared with traditional shelving
- Regulatory – regulators will treat new automated processes sympathetically if it can be shown that the processes are safe and a good audit trail is in place.
Automated systems are versatile and have the ability to handle unit doses, breaking of bulk supplies into accurately dispensed patient specific packs or original manufacturers’ packs.
Handling unit doses
The term ‘unit dose’ is used to describe a form of packaging in which each individual dose is separately packaged and labelled with the product name, strength and expiry date. A barcode identifier has been added in recent times. For solid oral dose forms, unit doses can be presented as individual, blister-packed doses, foil-wrapped doses or doses in individual sachets.
A different form of unit dose packaging is where a number of doses to be taken at the same time are packed in the same sachet. This form of medicines’ packaging has been used, for example, for patients in residential care homes, in sheltered accommodation or for patients living alone who may otherwise have difficulties with adherence.
Unit doses of liquid formulations can be provided in small tubs (like milk) or in plastic tubes. Unit doses of eye drops and eye ointment have long been available for use in emergency departments.
Many hospitals in Europe are moving towards unit dose drug distribution for hospital inpatients. As medicines are usually purchased in blister packs, machines have been developed to deblister manufacturers’ packs or to cut the manufacturers’ packs into unit dose blisters. These doses are then repackaged into sachets. A number of systems are available to automate this process.
Identifying your requirements
Pharmacists wishing to purchase a central robot are faced with a number of options and need to identify their requirements. The following points need to be considered:
- Original packs, unit dose or a combination of both
- Random storage versus channel storage
- Footprint – is additional floor space required at the back of the robot to enable staff to load it?
- Stock control – first in, first out; expiry dates
- Management information software
- Interface with pharmacy software systems
- Shape and size
- Conveyors and elevators
- Capacity – number of packs per unit area
- Spare capacity – to meet future demands
- Input – manual or automatic
- Speed of output
- Number of output locations
- Ward supply, individual inpatient supply, outpatient supply
- Integral labelling
- Back up systems
- Out-of-hours emergency supply
- Cleaning and prevention of cross-contamination
- Noise levels
- Value for money.
One message that comes over loud and clear from hospitals that have introduced centralised pharmacy robots is the importance of good project management during the planning, installation and commissioning phases. The larger the project, the more important the project management becomes.
Another important message is the need for adequate training of all staff involved in using the robot. Many hospitals have designated a senior pharmacy technician as the lead trainer. These individuals provide much-needed continuity and often find it a welcome career development.
Automation is here to stay. We must embrace the new technology and make it work for the benefit of the service and ultimately for the safety of the patients.