1. June 2011 Inpatient Pharmacy Workflow Processes and Daily Routine

2. Course Objectives Identify at least two steps involved in developing a strategic plan for improving a health system's process for preparing Compounded Sterile Products (CSPs). Discuss the need for patient safety-related improvements in the process for preparing CSPs in many health-system pharmacy departments Leverage HIT, data management, and workflow to strive toward the patient-centered medical care model

3. Course Objectives Configure Inpatient Pharmacy v5.0 site parameters for IV and UD menus Compare & contrast Inpatient Pharmacy IV and UD reports Use Inpatient menu options to perform routine daily IV and UD tasks Identify good practices for managing workload using Inpatient Pharmacy v5.0

4. Overview Daily inpatient pharmacy workload: IV Package routine tasks: - Printing reports/lists, Printing Labels, Manufacturing of IV’s, etc. Unit Dose Package routine tasks: - Printing pick list, cart-fill (if no Pyxis), entering doses dispensed, etc.

5. IV Menu Site Parameter Configuration IV Menu > Supervisor Option > Site Parameter Edit Allows configuration of defaults: Name(s) of IV Room(s) Label specifications Duration of orders for various IV types: Automatic stop dates different from the defaults may be entered for individual additives in drug file Coverage times (i.e., 24 hour batch time frame) Devices for output (reports, labels)

6. Daily Routine for IV Package Print Active Order List (optional): Review, update orders as needed Print Ward List Print Manufacturing List Print Scheduled Labels Prepare IV’s, check, deliver to ward

7. Daily IV Workload – Active Order List Prints list of all currently active IV orders: Sorted by ward Can be printed at any time Variety of uses as a worksheet: Take to ward and check IV admixtures for current rates, # of bags needed. Use to review IV antibiotics against culture results. Compare to MAR to see if nurses changed any administration times.

8. Daily IV Workload – Ward List Ward List prints all active orders: Sorted by ward Shows # of bags due for 24 hour coverage First step in sequence for daily IV batch: Ward List, then Manufacturing List, then Scheduled Labels (always in this order) Ward List is used by pharmacist to check each bag/label prior to delivery to ward.

9. Daily IV Workload – Manufacturing List Prints all active orders: Lists all admixtures first: Sorted by base solution, with totals Lists all piggybacks next: Sorted by additive and strength, with totals Used by technicians to assemble needed bags & additives, record lot numbers. After admixture, technician separates IVs by ward for checking by pharmacist.

10. Daily IV Workload – Scheduled Labels Prints labels for all IVs due for 24 hour batch: Labels print in same order as manufacturer list (batched by drug/dose). Good practices: Check printer before sending print job: Ensure labels correctly aligned. Ensure adequate # of labels. Watch labels to ensure they don’t curl back.

11. Other IV Menu options: Reprint Scheduled Labels Shouldn’t need to use this often: Especially if you follow good practices and watch the printer during scheduled label print job If labels jam partway through print job or run out: Can print selected range of labels From last usable label to end, or to next usable label

12. Other IV Menu Options: Individual Labels Print labels for one patient Program gives two choices: Reprint labels Print New Labels Program asks if the labels should “count as daily usage?” No for reprints Yes for new labels

13. Other IV Menu Options: Suspense Functions Allows labels to be suspended from printing with the batch Labels can later be released for printing Possible uses: High cost items Items that may be discontinued Items unlikely to be re-usable: Neonatal syringes, oddball admixtures

14. Other IV Menu Options: Returns & Destroyed Menu Used when IVs or IV labels need to be credited Labels that were printed but never mixed: Use Cancelled option Labels that were printed and mixed but can be re-used for another patient: Use Recycled option Labels that were printed and mixed and cannot be used for another patient: Use Destroyed option

15. Other IV Menu Options: Renewal List & Inpatient Stop Order Notices Reports that print orders that will expire in a selected time frame (e.g. next 24 hours): Renewal List prints only IV orders. Inpatient Stop Order Notices prints IV orders, U/D orders, or both. If your site has automatic stop dates: Use report to notify providers. Provider must decide whether to renew or let order expire.

16. Automatic Stop Orders (ASO’s) Are ASO’s necessary? Helpful? Good practice suggestion: Eliminate ASO’s in policy for most drugs. Configure RPMS parameters to maximum allowable stop date. Exceptions to consider: ketorolac, narcotics? For the exceptions, can set shorter ASO under orderable item file or additive file.

17. UD Menu Site Parameter Configuration Unit Dose Menu > Supervisor Option > Inpatient Ward Parameters Edit Allows configuration of defaults: Automatic stop dates for UD orders Start time calculation: Now, Next Scheduled or Closest Scheduled Automatic printing of MAR labels Default print devices

18. Daily Routine Workload for Unit Dose (UD) Package Print Pick List* Perform cart fill if no ADM (Pyxis/Omnicell) Enter Units Dispensed* Report Returns* * Process differs depending on whether or not your site has Inpatient ADMs with Profiling and Interface

19. Daily UD Workload: Printing Pick List Pick list prints all active UD orders: Sorted by Ward, then Room/Bed Shows doses needed for next 24 hours Used as worksheet to fill UD med carts If Pyxis or Omnicell, do not need to actually print: Still need to RUN Pick List, but can print to screen or enter “^”

20. Pick List - with Cart Fill Number of units dispensed is recorded on line. Items marked Ward Stock will show WS as units needed. Orders that are schedule type R (Fill on Request) will show zero as units needed.

21. Daily UD Workload: Enter Units Dispensed Allows pharmacist to enter into RPMS the doses actually dispensed for each med: Tip: when appropriate, simply Enter at prompt to accept that units dispensed = units needed Optional: view only prn med orders: For schedule types other than prn, program assumes units dispensed = units needed Program jumps past items listed as WS: When finished, you are prompted: “May I file this pick list away”?

22. Daily UD Workload: Enter Units Dispensed (Sites with ADM) Bypassing Enter Units Dispensed entry: At first patient, enter “^^^” to skip to the end. Program automatically accepts units needed equals units dispensed for each item. Caution - if any item is not marked as WS the program will double count: Pick List doses plus doses removed from ADM Good Practice – do the complete Enter Units Dispensed, at least periodically.

23. Other UD Menu Options: EXtra Units Dispensed Used to enter extra unit doses dispensed: e.g., lost, dropped Fill on Request items (e.g. new tube of cream) For sites with ADM (Pyxis/Omnicell): Use this option if item not stocked in ADM. If item comes out of ADM and nurse removes extra dose, it is recorded automatically.

24. Other UD Menu Options: Report Returns Used to credit unit dose meds: When patient is discharged When order is discontinued If your site has ADM with interface: Meds returned to ADM by the nurse will be subtracted in RPMS automatically Still may need to use this option: e.g., Albuterol inhaler prn - dispensed but never opened/used

25. Summary Inpatient Package Daily Routine Tasks: IV Menu: Ward List, Mfg List, Scheduled Labels Other options as needed UD Menu: Pick List, +/- Cart Fill, Enter Units Dispensed Other options as needed