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A review of the installation and factors for consideration
Ann Mounsey
Site Lead Pharmacist for the Charing Cross Hospital
Ann Jacklin
Chief of Service, Pharmacy and Therapies Imperial College Healthcare NHS Trust and visiting Professor School of Pharmacy University of London
Susan Newton MRPharmS DMS
Executive Lead Pharmacist for Hammersmith Hospital
Automated pharmacy retrieval systems (robots) are now in widespread use in the UK. From their first introduction at St Thomas’s Hospital in 2000, many pharmacies now have this additional “member of staff”. Often given a name and referred to in human terms, they quickly become a member of the team. These pieces of technology, which are rarely ill, do not go on holiday and have no problems travelling to work, now play a vital role in many hospital dispensaries and pharmacy stores. Well over 100 hospitals in the UK either have one already installed or are going through the purchasing process, and with five different companies in the market there is lots of choice.
This article briefly looks at automation and some of the practical issues which need to be addressed when considering the installation of a pharmacy-based dispensing robot. It draws on our experience within the pharmacy departments at Charing Cross and Hammersmith Hospitals – both acute teaching hospitals and part of Imperial College Healthcare Trust. With a total of approximately 1,100 beds representing all major pecialities, the dispensaries are busy and both have robots.
Charing Cross has a Swisslog Pack Picker, which since originally going live with two picking heads in April 2004 has been doubled in size. The robot stores chaotically with a system of preconfigurable shelves. Each shelf can hold up to five different products and gives a large amount of storage space in a small footprint. The Pack Picker has one semiautomated loading system feeding the four modules.
Hammersmith has an ARX-ROWA Speedcase. Originally going live with one module in October 2005, a further module and a Prolog automatic loading device have since been added. Each module has horizontal shelving either side of a central picking head storing products up to two deep, in defined positions making maximum use of the space available.
Automation – the benefits
The organisational benefits of automated dispensing systems were described in the Department of Health publication “Pharmacy in the Future: Implementing the NHS Plan”. [1] Published in 2000, it advocated the use of modern technology to remove some of the repetitive tasks involved in dispensing to increase the accuracy of dispensing and to free up hospital pharmacists’ time to focus on clinical care. This was further enforced with the Audit Commission report in 2001, “A spoonful of sugar: medicines management in UK hospitals”. [2] This emphasised both the use of original packs for dispensing as well as the use of pharmacy automation.
Many articles have been written on the advantages of robots which demonstrate that there are a number of areas where improvements and benefits can be realised. Whilst some benefits are largely intangible, others can be quantitatively assessed.[3,4]
Locally we have seen a number of benefits, which include: a reduction in dispensing errors, a smoothing of the dispensing process and a decrease in time spent walking to pick stock. As a result of this we have freed up staff for other activities, including increased clinical time on the wards and undertaking outpatient oral chemotherapy screening. Our rotation of stock, with the robot working on a “first in, first out” approach is guaranteed, resulting in a reduction in expired drugs and improved stock management. We have been able to make better use of space within the dispensary, enabling us to move shelves and increase the space available for dispensing, rather than storage.
Automation – issues to be considered
When embarking on dispensary automation a wide variety of issues have to be considered. The following serves to give a brief idea of some of the project steps we have had to undertake and the issues we faced.
Business case
The likely starting-off point is the writing of a business case, the formal proposal presenting the case for change and the investment required. This will be considered by a Trust board or equivalent, and once funding has been agreed the next stage will be the tendering process.
Procurement
Under current regulations any NHS supplies or service contracts in excess of approximately £90,000 have to go through the EU tendering process. The NHS Purchasing and Supplies Agency (PASA) have a useful toolkit on pharmacy automation that can be used to help in the procurement, adjudication and implementation of your system (www.pasa.nhs.uk).
Project management
A project team should be formed. Individuals from the dispensary, computer services, information technology (IT) and estates departments should all be considered. Regular project meetings should be held with updated action plans and operational outlines.
Installation of automation requires a number of contiguous activities, some of which can carry on in isolation and others which interlink. For example, the design of the interface between the robot and the pharmacy computer system should be commenced at the beginning of the project, allowing for any development time, even though it may not interlink with other activities until towards the end of the project. Thought, however, may need to be given to the ratio of different shelf sizes early on in the project as the specification and manufacture of the robot may be dependent on this. The development of a project plan will help to identify these activities and those which may be rate-determining steps.
Choice of automation
A large number of factors may influence your choice of robot. One of the most important questions is what do you want to use your robot for? Is it just for dispensing or is it for ward stock or both, and how much space do you have available? Space will govern robot size, which in turn will influence capacity. A small robot can hold many thousands of eye drop bottles but not so many inhaler spacer devices!
What shapes, sizes and weight can the robot cope with? Can both the robot and the delivery system cope with nonrectangular products and heavy products? Most robots have configurable storage compartments/ shelves, and consideration may need to be given to how many of each size you require.
What optional extras are available – do you want a fridge module, automated labelling, remote access, connection to pneumatic tubes or an automated loading device?
Location
The robot needs to be located to optimise workflow. Is it to be located in the dispensary or elsewhere? Is the infrastructure of the building suitable? Are you having conveyor belts, lifts, chutes, slides or flaps to allow delivery of items to the user? Where do you want these output locations to be, and how many do you want?
Heat and noise generation need to be considered if conveyor belts are required – will they need to be boxed in to minimise noise? Is there sufficient head space to allow air to circulate? How are temperatures inside the robot monitored?
IT aspects
IT is another essential aspect. IT issues include barcode reading (does the robot have the ability to read all types?) and the speed of the interface between the robot and the pharmacy labelling system. In addition, will the interface be “one-way” or “two-way”? A oneway interface sends the request to the robot but does not give any information on stock availability back to the user. A two-way interface allows a message to be sent back to the user as to the status of the request.
How is the inventory going to be loaded and how will it be updated? How does your robot cope with contract changes and more than one brand of the same product at the same time?
If your robot will be used for both individual patient dispensing and ward stock issues, do you want your system configured to prioritise picking from one particular terminal, such as that used for outpatients?
Installation and enabling works
Choosing your robot is only half the process, and the amount of preparation for installation should not be underestimated. A major challenge is keeping your dispensary functioning around the installation work; this is clearly easier if the robot is being installed into a new build. Factors to be considered include everything from delivery and storage of your robot whilst being built to electrical services supply, telephony and data communications.
Going live
Once the system is installed, tested and working, a decision will need to be made regarding “going live”. Will you load all your stock and fill to capacity immediately, or will it be a slower, more gradual buildup, starting with just a few products? If the “big bang” approach, the time taken to load all your stock should not be underestimated. How are you going to train your staff, and what are the procedure manuals like? Will you have “super-users” and password control to various programmes and various levels? Who will be responsible for housekeeping and updating, and what sort of audit and housekeeping reports would you like/ are available?
Process changes
What is going to remain spacewise after the robot has been installed, and what is the layout of your dispensary/ stores going to be like? Have you got appropriate space for stock that cannot go in your robot, and has a decision been made about how you will deal with returns from the wards and partly used original packs? Do you need to alter the daily work processes – do you still want to pick ward boxes in the middle of the day? Do you want dispensary deliveries for loading at a different time?
Disaster recovery
Things can go wrong, and robots like all other mechanical devices will. You will need a contingency plan in the event of mechanical/computer failure. Are staff going to be allowed to manually remove products, and how do you ensure that this data is captured? How easy is it to clear if a product is “stuck” – do you need ladders (and consideration of the health and safety implications for staff climbing ladders)?
Can you take part of the system down for maintenance, leaving at least one module/picking head running? Does your robot have an uninterrupted power supply, and can it cope with generator testing? Can it work if your pharmacy computer system is working in standby or on “local service”, and what requirements are there from your organisation with regard to firewalls and remote access?
Maintenance
What is the cost of your maintenance contract, and what level of service does this provide? Are there additional costs incurred by your pharmacy computer service provider? Is there a telephone helpdesk and, most importantly, how long will it take to call an engineer in?
Impact on staff
Finally, what is the effect on the staff? Individuals may need to be allocated new jobs and/or tasks, as their daily work pattern may change. Not all staff may immediately benefit from the advantages that automation brings. Staff need to be kept updated and involved as much as possible. In the enormity of the project it is important to ensure that this is not overlooked.
Conclusion
Whilst the use of automated dispensing systems undoubtedly offers great advantages, they are not wholly suited to all situations and a degree of pragmatism is required. Many of the early robots are designed to handle individual packs, and therefore multipacked items in cellophane outers (eg, injections packed in blocks of 10) have to be unpacked before loading and subsequently dispensed as individual items. For some products this may cause significant handling problems, both in the dispensary and on the wards. Unlike some hospitals, therefore, we do not put all of our products in our robots, only those for which we get a nett benefit. Pragmatism is essential to ensure that you are the ruler and master of your robot, rather than the robot ruling you!
User satisfaction with automated dispensing is determined by a number of factors, not least the reliability of the system. In our experience, user experience of automated dispensing can swing to extremes of love and hate: when working well (by and large, and fortunately, most of the time) it is significantly better than the previous manual systems; in contrast, in the rare instances of malfunction, user dissatisfaction rises significantly. User satisfaction is also closely related to experience; longer-serving staff with comparative experience of “all-manual” dispensaries tend to be more satisfied with automated dispensing than newer staff who know no alternative. What was originally exciting and new soon becomes normal.
References
1. Department of Health. Pharmacy in the future – implementing the NHS Plan. London: DH; 2001.
2. Audit Commission. A spoonful of sugar: medicines management in NHS hospitals. London: Audit Commission; 2001.
3. Slee A, Farrar K, Hughes D. Implementing an automated dispensing system. PharmJ 2002;268:437-8.
4. Goundrey-Smith S. Pharmacy robots in UK hospitals: the benefits and implementation issues. PharmJ 2008;280:599-602.
