Dr Michael Baehr
Simone Melzer, MBA
Apotheke des Universitätsklinikums Hamburg-Eppendorf, Hamburg, Germany
The University Medical Center Hamburg-Eppendorf (University Krankenhaus Eppendorf [UKE]) is a general teaching hospital with 1,500 beds and 490,000 inpatients a year. For a long time, medication safety has been an important field of activity at the hospital pharmacy of UKE. International studies on medication errors and our own studies on error frequency in oncology prescriptions became the impulse for a project to reorganise the whole medication process.1 Following international recommendations, the aim was to implement computerised physician order entry within the electronic patient record, supervision of the prescriptions by clinical pharmacists, delivery of unit doses by the pharmacy and at least electronic registration of drug administration by nurses to close the medication loop. A complete reconstruction of the main hospital building combined with the introduction of new workflows and medical processes gave the chance to realise this project.
Electronic prescription – a part of the electronic patient record
In October 2008, the patient record was comprehensively transferred to the electronic system “Soarian Clincals”.2 This electronic patient record covers a wide scope of clinical processes but unfortunately the medication process is not (yet) integrated. So the Automatic Tablet Computer Host (ATCHost) prescribing system had to be connected with different interfaces as an external system.3 ATCHost has thus become an integral part of the electronic patient record. The basic requirement for accepting this concept was that the electronic patient record is available at bedside. That’s why an effective W-LAN connection was installed in the new clinic and mobile trolley PCs were equipped with sufficient battery capacity. Every ward has several mobile work stations to provide easy access to all clinical data during ward rounds.
ATCHost covers computer physician order entry (CPOE)-functionalities and supports logistic unit-dose supply processes. In addition it has many useful features that support the physician’s prescribing process, see box below.3nds]
Unit dose dispensing with Baxter FDS
Unit doses are produced using Baxter Fast Dispensing System (FDS) 330 and since 2010 Baxter FDS Proud 336. Two major considerations led to the choice of these systems. On the one hand, the CPOE-software ATCHost with all interfaces to the machines is offered by Baxter as a ready-to-use system, and on the other hand the FDS is able to produce the bags very rapidly, at least up to 40 single bags per minute.
This velocity is important when supplying an acute hospital where all ward rounds happen simultaneously in the morning and changes of medications are frequently made.
Additional reasons for choosing this type of machine its comparatively low invest costs for hard- and software, the robust and mechanically simple construction and the low required space. The dimensions of the Fast Dispensing System (FDS) 330 are 1.00m wide, 1.00m deep and 2.04m high with a weight of about 750kg. The FDS only requires 220V from a standard power source.
Last but not least, in the past we made a complex unit dose system that could package oral and non oral forms of medications such as vials, ampoules and syringes. We saw that packaging non-oral medication and bundling it with oral medication does not meet the clinical requirements on the ward, because oral medication can be given directly to the patient while non oral medication needs to be prepared before application by the nursing staff. Patient-friendly packaging of non oral medication was time consuming and expensive and gave no added value on the ward or to the patient.
Today the wards in our hospital are supplied by the pharmacy once or twice a day, according to their clinical needs. After the pharmacist has validated the new prescriptions, orders are sent from ATCHost to the FDS machines via an integrated interface.5
Baxter’s FDS-330/Proud device packs the solid oral dosage forms. The bags are labelled with all useful information such as ward, room, patient name, medication, dosage and advice for intake. The FDS-330 contains 330 containers, and FDS Proud has space for 336 containers for different oral medications. Via a detachable table, medications not on the formulary or half tablets can be added to the packaging process. All other single-dosed drugs (eg, ampoules, syringes and suppositories) are picked manually according to prescription, labelled and delivered in time for every ward. Pro re nata (PRN)-medications, medications for emergencies and all multi-dosed formulations like ointments or multi vials have to be stored in ward stock.
Electronic registration of drug administration
To close the loop, the documentation of administration is the last step in the supply process. The separate documentation add-on secure drug administration (SeDrA) was programmed for this purpose. SeDrA can be accessed from the electronic record and works on the basis of the ATCHost prescription database. With only a few mouse clicks the nursing staff can register the administration of all prescribed drugs. Medications which have been added, stopped or changed after the packaging process in the pharmacy are displayed in red in SeDrA. These medications cannot be marked by the button ‘register all’ but have to be marked separately.
If a drug is subject to batch control, the input of the batch number is required for the registration.
If a medication cannot be given, the nurse has to enter a reason. A list of predefined reasons can be created by every user.
Single doses, e.g. phone prescriptions, can be documented in SeDrA as well. In this case a reason must be entered. The physician can see all data documented in the administration record.
Unfortunately SeDrA is not developed for bedside verification. Although our units contain barcodes and every patient wears a wristband with the admission ID encoded in a barcode there is not yet a possibility to register the application by a barcode scan.
The role of clinical pharmacists
Two years before starting the unit-dose project, two clinical pharmacists were established in UKE who without involvement in the logistic process have given the most significant clinical pharmaceutical support.4,5 The success of the introduction of clinical pharmacists made clear that a technical process like the new unit dose process must be supported by pharmacists on the wards as well. Consequently the daily presence of pharmacists was introduced. ATCHost provides the role of the clinical pharmacist. The pharmacist can display a list with every single new prescription. During his ward visit he checks these prescriptions for interactions, adjusts dosages if kidney or liver function is limited, considers early switches to oral medication and advises on economical pharmacotherapy.
The work of our clinical pharmacists as well as the unit-dose supply itself is well accepted by physicians and nurses.
Using Baxter’s FDS combined with the CPOE-software ATCHost, it was possible to implement the medication process in a closed loop. In a one year period, 26 normal wards, three intermediate care units and six intensive care units with at least 750 beds were covered with the new medication process.
For a successful realisation of the project, some items were especially relevant. The project plan was the main base for the ambitious time schedule. It was created by the interdisciplinary project team (physicians, nursing staff, other personnel, project management, pharmacists) and implemented by the pharmacy.
A written ward agreement including the delivery schedule was made for every ward. Communication with the ward personnel, the pharmacy’s knowledge of ward specialities and the information from all involved parties were the basis for a smooth implementation.
The involvement of the IT-department to provide fast and reliable support and problem solving is an essential requirement for an IT-based process.
The pharmacy has taken over a number of new assignments and responsibilities with the implementation of the new process. Almost all pharmacy staff participated in it. Internal qualification and training were needed. Changes in working hours were necessary.
The support and cooperation of the management board is indispensable. With the help of frequent and constructive communication, the project was integrated in the hospital’s overall concept.
With the new FDS Proud 336, the complete rollout of the unit-dose supply system for the missing 750 beds of our university hospital was started in December 2010 and will be finished in March 2011. Due to the fact that ATCHost is already used on the wards which are not yet connected to the unit-dose supply, the rollout will be much quicker than in the first phase of the project when neither physicians nor nurses were used to the electronic patient record. The impact of the established unit dose system on patient safety, satisfaction and pharmaco-economics are being studied and results will be published.
- Baehr M et al. Krankenhauspharmazie 2002;23:287.
- Siemens AG. www.medical.siemens.com/webapp/wcs/stores/servlet/ProductDisplay~q_catalogId~e
- ATCHost Baxter Pharmacy Automation, Utrecht, Holland. www.baxter.nl/beroepsbeoefenaar/product/geautomatiseerd_geneesmiddelenverstrekking/geautomatiseerde_geneesmiddelenverstrekking.html
- Langebrake C & Hilgarth H. Krankenhauspharmazie 2008;29:83-9.
- Langebrake C & Hilgarth H. Clinical pharmacists’ interventions in a German University Hospital. Pharm World Sci 2010; DOI 10.1007/s11096-010-9367-z