Unit dose versus one stop dispensing

There is a growing interest in the provision of unit doses to support the treatment of in-patients.¹ In 2001, when ‘one stop dispensing’ was first introduced, the concept was to have the patient’s medicines supplied in a ‘ready for discharge’ format as soon as possible after admission. Because the majority of the medicines that the patient was taking on admission were unchanged at the time of discharge, the concept of ‘one stop dispensing’ seemed logical.

The initiative was part of a business transformation project, linked to the introduction of an automated dispensing system, which had the aim of rationalising inventory and reducing ‘stock-out’ issues; reducing storage space; reducing dispensing errors and releasing pharmacy staff to ward-based activities. These aims were achieved and reported at the time.²

The project was largely funded through savings in the primary care drug budget. Dispensing for discharge meant that patients were discharged with a minimum of two (and often closer to four) weeks’ supply of medicines which, when the difference between primary care and secondary care costs were calculated, provided significant savings that were more than sufficient to fund the project. These savings were validated by HM Treasury and actually informed the Treasury guidance to primary care trusts and general practitioners in 2001.

This change also had the following benefits:

More recently, there has been much discussion about ‘waste’ of medicines and a suggestion that we should move to unit dose dispensing of medicines as a way to achieve a reduction in administration error and reduce the ‘burden’ of wasted medicines. So what has changed?

The mean length of stay for all admissions has reduced from 7.9 days to 5.2 days. The cost of hospital ‘contract’ medicines has kept pace with inflation but remains a fraction of the cost of the same medicines in the primary care setting. There are certainly reports on the shortage of nursing time but national figures of nurse numbers are not aligned to the idea of reduced availability of nurses (but national figures do not always relate to ‘boots on the ground’). So why is there a call for change?

The use of unit dose dispensing has been common in the US for some time. Doses are dispensed for an individual patient on a 24-hour supply basis and pharmacy services necessarily run a 24-hour, seven days a week operation to facilitate this. One of the many reasons quoted for this process is patient safety; but an electronic prescription, verified by a pharmacist and validated at the point of administration by barcode validation (whether of a unit dose or an original pack), would provide just as much (if not more) by way of patient safety.

A process that involves repeated dispensing of the same items can add significantly to the cost of supply without necessarily adding value to the management of medicines. Although new innovations in the technology to produce unit doses can improve upon the time taken to generate these, the process still adds cost, and even if the pharmaceutical industry could be persuaded to generate unit dose packs (unlikely, given the decades of use of unit doses in the largest healthcare market in the developed world – without an industry response), these would attract a pricing premium.

In hospitals in the UK, patients need a supply of the medicines prescribed for them to support administration in hospital and again on discharge. The supply on discharge is necessarily a minimum of one week and is outside of the provision of a unit dose solution. Commonly used medicines can be available on wards (whether as unit doses or as original packs), but the provision of a supply of medicines required by an individual patient, and not readily available on the ward, is a challenge for any supply process; particularly as admission of patients is a 24-hour a day, seven day a week process but most pharmacy departments are not resourced to offer a seven days a week service. This necessarily entails a delay in the provision of medicines for patient care whatever the form of medicines supplied. Managing this issue has often led to the use of ‘patients’ own’ medicines, further complicating the supply process and the process by which nurses identify what is to be used for the treatment of an individual patient.

If medicines are supplied in a ‘ready for discharge’ format as soon as possible after admission, there will inevitably be some medicines that cannot be supplied to the patient on discharge because the medicine has been discontinued or the dose changed, making the old strength unsuitable to meet the requirements of the new dose. These are described as ‘wasted’ medicines as they cannot be used for the patient for whom they were originally intended and need to be recycled in some way by pharmacy if they are to be used at all. (Some units re-label these partly used packs and use them as ward stock items). Experience suggests that much of the ‘waste’ comes from nurses not being able to ‘find’ the medicines that have been supplied and so requesting and receiving an additional supply (or two) which are eventually returned to pharmacy (sometimes in a part-used state).

Pharmaceutical waste can be problematic to dispose of, and steps should be taken to support ward staff in minimising such ‘waste’ of medicines (unnecessary re-ordering of medicines that have been supplied but cannot be located when needed is one significant cause of waste that can be managed by good business transformation support). If the cost of such ‘waste’ is the underpinning driver for an investment in unit dosing, such a business case should be assessed rigorously before a ‘unit dose’ solution is proposed or adopted.

Medicines need to be made available to ward staff in a timely manner, to facilitate the treatment of in-patients. Medicines need to be identifiable to the staff giving the medicines and able to be ‘reconciled’ against the prescription. (Ideally, ePrescribing systems will soon be more widely available, with the ability to ‘validate’ the medicine selected – identifiable by the barcode on the pack or (for unit doses) on the label – against the individually prescribed item.) To support the administration process, medicines need to be readily available at the patient’s bedside, when they are needed: either by means of a ‘trolley’ that keeps the medicines secure during administration or by some other means; and ‘original pack dispensing’ envisaged the use of patient lockers at each bedside, ensuring a comprehensive supply of medicine availability and supporting, where appropriate, initiatives to promote self-administration by patients. A similar process would need to be in place to support unit dose dispensing, presumably on a daily basis?

Let us be clear, there is already a mixture of supply to meet the needs of patients; some unit doses (normally ready-made injectable agents, such as antibiotics, parenteral nutrition and cytotoxic agents); some original packs (ward stock items or re-use of a patient’s own supply or items for ‘immediate use’ such as GTN spray); and some items supplied specifically for an individual but not as an original pack (ready for discharge) and more as a short term/temporary stock – often labelled with the name of the individual patient but with no directions.

In the same way that original pack dispensing required a business transformation initiative (which seems to have been less than successful in a number of circumstances), a change to unit dose would require extensive support and education to ensure success.

A number of hospitals have invested in automated dispensing systems that support original pack supply. Where discharge prescriptions continue to be a feature of hospital practice, these will still be required, even following a change to unit dose dispensing. (A debate has been initiated about the provision of discharge dispensing by ‘external’ providers, with some suggestion that this, similar to out-patient dispensing, could be VAT-releasing.) Such arrangements would need to be restricted to identified suppliers that could dispense medicines at ‘hospital contract’ prices – and so would not universally be ‘easier’ for patients. A wholesale change to such a model would undoubtedly attract the interest of Treasury, inevitably leading to closure of any VAT ‘loophole’.

So, what would be the process by which unit doses are provided, and what advantages would this bring? Apart from a brief foray into the provision of ‘hospital packs’ (including some ‘mini-inhalers’ that caused some confusion for patients), the pharmaceutical industry has seemed reluctant to provide medicines in a unit dose format. It is perhaps not surprising that, in an extremely price-sensitive market, where such an increase in packaging costs must be passed on in terms of increased prices, no-one is keen to take the first step.

So unit doses would need to be ‘created’ on-site (or perhaps through a centralised collaboration) to a ‘good manufacturing practice’ level of quality. Such doses are (in all the examples I have seen) extremely similar in presentation (clear plastic envelopes with the medication details on the printed label), making the quality and accuracy of the re-packaging process crucially important in ensuring patient safety. There is also an imperative to ensure that the labelling is clear, easily readable and able to be differentiated from any similar looking/sounding items by the nurse administering the product.

This would require investment in more ‘kit’ (in the guise of automated systems) to facilitate the creation and supply of unit doses and a ‘manufacturing process’ (with the necessary resources) to support this process. The ‘better’ systems I have seen ensure that the supply from the automated re-packaging system is transferred directly to the ward and thence to the drug trolley, with the need to invest in the necessary integrated trolleys, etc. Each medicine is, of course, identifiable to an individual patient by barcode (or other machine readable mechanism) as well as by text on the label.

In most unit dose solutions ‘exceptions’ are made for various items, such as inhalers (original pack supplied for individual use); insulin (often a similar solution, particularly if the patient uses a pen-injector); GTN (spray or tablets), as these need to be directly available to the patient; and creams and ointments.

One of the more contentious areas if how liquid medicines are managed (particularly items such as liquid laxatives administered on an ‘as required’ basis). These items, together with the ‘traditional’ unit dose items, such as aseptically prepared injectable agents, tend to be ‘exclusions’ from this automated unit dose process.

So can such investment be justified by the reduction in ‘waste’?  If the business transformation effort is to be invested in any case, it could just as easily be invested in improving the use of ‘original packs’ rather than in a new process. So where is the real business benefit to be obtained?

In a world of immediate communication of electronic prescriptions and links to automated dispensing systems, it is not inconceivable that, once verified by a pharmacist, medicines could be automatically picked and supplied to the ward. Mechanisms to transport the (automatically) supplied medicines exist (for both unit doses and original packs) and apart from the initial verification process, this supply would be ‘pharmacy-lite’. Indeed, depending on the tolerances set around the supply of the first dose (which will most often be administered at the next drug round rather than immediately) – such systems could even be off-site; allowing multiple hospitals to be supplied from one central unit.

Advances in technology, coupled with the availability of ePrescribing, could allow the re-engineering of the process to supply medicines to wards. Whether this is facilitated by unit dose or original packs, or whether supported locally or from a central supplier (perhaps even a wholesaler?), the opportunity exists for a step change in the medicines supply process. Pharmacy needs to ensure that the contribution it makes is in adding value to the care of patients with medicines; optimising choices; providing information and education and signposting and communicating to community practitioners; (GPs, community nurses and community pharmacists) where patients have ongoing needs to support their effective use of medicines. If the automation revolution is to catch up with us, I hope our discussions are around ‘how does this allow us to provide greater benefit to patients?’ rather than ‘how many tablets will I save by changing the process?’