A case study from the Sunderland Royal Hospital in the UK shows how distribution of intravenous fluids was made more efficient from the pharmacy perspective
Rod Beard BPharm MSc MBA MProf MRPharmS
Sunderland Royal Hospital, UK
In the climate of austerity across Europe, many hospital pharmacies are increasingly being put under pressure to reduce costs. Hospital pharmacies look at a variety of methods such as centralising and rationalising distribution points, utilising robots, or other methods to make the distribution processes more efficient. One of the more difficult areas lies with IV fluid supplies to hospitals, and this is primarily because of the bulkiness of the fluids. Improving IV fluid distribution is perhaps not as glamorous as some other aspects of pharmacy service, but no less an important one. However, there are approaches to consider how this can be made more efficient from the pharmacy perspective. This is a small case study on how Sunderland Royal Hospital
Sunderland Royal Hospital has approximately 1000 beds, and provides services to the population of Sunderland (around 350,000). It also provides increasingly services to a wider region, for some clinical specialities (up to 1.5 million people). During the course of a single week, the hospital will use approximately ten tonnes of IV fluids (for example, sodium chloride 0.9%; dextrose 5%; compound sodium lactate solution; water for irrigation). This means that each week, ten tonnes of fluids need to be delivered around the site – a significant task. Several years ago, the pharmacy had discussions with its supplier (Baxter) and arranged for IV fluids to be assembled for ward delivery. This removed a significant amount of double handling. However, there were still problems with deliveries to wards, which represented internal problems in the hospital. Because of the bulkiness of the pallets containing ward orders, the drop-off point in the hospital had to be at ground level.
The drop-off point for deliveries also had to be large enough to cope with the 70 IV fluid locations (wards and departments). To meet audit requirements to approve invoices, delivery of fluids was checked against the orders, and then taken to onward distribution to the wards by the hospital porters. This represented a significant amount of time checking the orders because they were away from the pharmacy, and the consolidated pallets harder to check against the goods received note. The scale of the deliveries was also a problem for porters. The hospital is a large six-storey building, so lift access during the day can be a problem for pallet delivery. Also, the porters have a range of demands, and fluid delivery would come as a low priority compared with some other tasks (moving patients, delivering medical gases, removing bodies to the mortuary etc), especially if there were staff shortages. The impact of all these factors meant that, on some occasions, fluids could be stood in the delivery area for two or three days, which would disrupt ward supplies of IV fluids.
The consequence of this was that there were a significant number of requests for fluids outside of the pallet delivery days. This meant the pharmacy was stocking perhaps more fluids than was necessary, and was carrying out increasingly more manual handling. When managers looked at the arrangements, they were somewhat chaotic, and a process map and observation showed the prime weak point in the process was delivery from the pallet drop-off point to the ward. This was completely out of the control of the pharmacy, and had a significant impact on the timeliness of IV fluid supplies. Significant amounts of pharmacy time was spent tracking where ward IV fluids were in the system. They could be at the distribution point (not near the pharmacy), perhaps already delivered, or delivered to the wrong place.
The necessity to improve the aspect of service was highlighted with the deaths of three patients at Stepping Hill Hospital in Stockport, via contaminated IV fluids, and in a subsequent news item identifying many hospitals, including Sunderland, as having poor IV fluid distribution practices.(1,2)
In 2012, the pharmacy at Sunderland was approached by Baxter regarding inventory management. Baxter was aware that the problems of fluid distribution at Sunderland was not untypical of many hospitals, and wanted a trial site to see if they could improve the service the ward received. The concept was to remove all the uncertainty around fluid distribution by allowing the supplier to control the whole process. To do this would require a complete re-think of how we would approach this task to ensure fluids were received by the ward in a timely fashion.
Sunderland’s IV fluids supplier (Baxter) must also have considered the request for traceability, and offered Sunderland to try a new service. This was for a complete out-sourcing of providing IV fluid supplies. The key was having each box uniquely identified by a barcode to manage traceability within the hospital (this is in line with the EU directive 2011/62/EU).(3) It also follows the principles our pharmacy is developing in using technology to perform mundane tasks, and focus on higher professional activity. The first part of the solution was to have Baxter personnel arrive with the deliveries of fluids to immediately take them to the ward, removing the variation in delivery times pallets were in the hospital. The consequence of this would mean ward stock should reflect more accurately the wards’ needs, if a reliable delivery service was in place.
The second proposal concerned lift access. The best time to distribute fluids around the hospital was when the lifts were not in use. It was proposed that this be done in the early morning, when lifts were easily available, and minimum time would be spent on this part of the process. It was further proposed that, unlike existing portering arrangements, the Baxter staff would put the stock away for the nurses. In doing this, they would be able to see what stock had gone, and what the likely re-order levels were.
The third proposal concerned adequacy of space for wards and departments to store IV fluids. As part of the service, each area scheduled to receive the service would be assessed for storage, and if extra storage was required, this would be provided by Baxter. The solutions were varied, ranging from extra shelving space, to purpose made trolleys to store either 12 or 20 boxes of fluids. The customisation of the storage was an important part of the process. Infection control requirements were to avoid boxes being stood on floors, as this prevented proper floor cleaning.
The fourth proposal was that, if the Baxter staff were dealing with putting stock away, they were in an ideal position to re-order for the next delivery and it was agreed that this would be carried out by Baxter staff. Of the 71 distribution points around the hospital, approximately 30 were identified as needing this service. The other areas were more ‘occasional’ IV fluid users.
The fifth proposal took into account our audit requirements, so we could verify invoices for payment. This would be based on technology. Each and every box would have a barcode as unique identification. This would make the IV fluids compliant with the directive 2011/62/EU, the so-called ‘counterfeit medicines directive’. It also meant there was a system to check if the boxes on the delivery note had actually been delivered to the ward or department.
The pharmacy required that this needed to be delivered at no extra cost to the hospital. While there were some extra costs in such a service, there were also potential areas of savings. If this could be achieved, it would significantly improve distribution of fluids around
The pharmacy did a series of assessments for the new service. Besides looking at operational matters, a qualitative survey was also done, asking nursing staff if the new service seemed an improvement to them. The operational benefits are summarised in Table 1 and the questionnaire results are summarised in Table 2. The questionnaire had a five-point scale for each question, with 1 as very poor, and 5 as very good. A neutral ‘3’ allowed respondees to record a ‘no difference’ result. The use of numbers allowed the responses to be numerically evaluated.
There was a significant reduction in the time taken to deliver IV fluids across the hospital. It dropped from one to two days to between four and six hours. This made a big difference to stock control, and demands from wards between deliveries. Ward stockholding did not reduce, but is now more appropriate to needs. The time to deliver decreased because this was the primary job of the company, and not a low priority from a list of other tasks the normal hospital porters were charged with. Also, attention was paid to the timing. Delivery starts around 7am, when the lifts are barely used. This means the person who moves the stock to the ward can quickly get fluids to any of the six floors of the hospital before others start to use them.
It is then a matter of putting the stock away on the wards. This is done by the nursing staff, so products are consistently put in the same place, and thus easier to find. Special trolleys were made for theatre areas, so that these were easy to replenish with boxes of fluids, without the need for gowning up, and individual theatres were topped up from the trolleys. This saves time for the person who delivers fluids into the theatre areas. Timely delivery was an important aspect of the project, as it was this that was identified as a problem in the news item.2 The cost of implementing the service was offset by a reduction in portering costs. An audit of the number of requests to supply IV fluids fell by 30%, reducing further workload. A survey of nurses’ views on the new service was conducted, and there was a very positive response to this.
Key to the process is the unique pack number on each box, which identifies if wards have been borrowing from each other due to surges in requirements, or had requested further supplies from the pharmacy. This permits constant monitoring of changing needs in wards requirements. It also provides a means to audit deliveries.
The change in system achieved the objective of improving IV fluid distribution without any increase in expenditure. The system works well, and those wards that receive the service (approximately 30 of the 71 distribution points) prefer it to the previous methods of delivery.
- The service considered storage needs for each area, and rectified insufficient capacity.
- Unique numbers on each box allows for easy audit checks of deliveries.
- Unique numbers on each box identifies if additional supplies to a ward are have been made (from pharmacy or another ward)
- The service considered storage needs for each area, and rectified insufficient capacity.
- Service was more timely than previously.
- Overall service process was controlled by one party, meaning no fragmentation of responsibility.
- 2011 Stepping Hill Hospital poisoning incident. http://en.wikipedia.org/wiki/2011_Stepping_Hill_Hospital_poisoning_incident (accessed 6 March 2014).
- Drug security: Hospitals named and shamed. 27January 2012 Sky News. http://news.sky.com/story/920789/drugs-security-hospitals-named-and-shamed (accessed 6 March 2014).
- European Directive EL (2011) 62. The ‘fraudulent medicines’ directive. Section 11. This requires manufacturers to put unique pack identification onto each and every pack. http://ec.europa.eu/health/files/eudralex/vol-1/dir_2011_62/dir_2011_62_en.pdf (accessed 6 March 2014).