Jonathan Shaatal, RPh, MS
Director of Pharmacy
Four Seasons Nursing & Rehabilitation Center
Parkshore Healthcare, LLC
Technology in use: AmerisourceBergen FastPak EXP

Cleaning and Maintenance
One of the few ways a high-volume packager can jam is if the machine is not kept clean and dust free. Since many tablets and capsules pass through the various areas within the machine, fragments can chip off. While this does not pose any health danger to the patient, these pieces can become caught in the conveyor belts, packaging paper, printer ribbon, and other moving parts. One solution is to vacuum the machine with a HEPA vacuum and wipe down all of the internal surfaces with a lint-free cloth on a regular basis. This is especially important after a long packaging session. Establishing standard cleaning sessions, as well as "as needed" scenarios, will minimize service calls and disruptions to the packaging schedule.

Determining Necessary Capacity
Most high-volume unit dose packagers have a maximum capacity of fast moving medications as well as the ability to add medications as needed. To determine the capacity you will need, evaluate current volume needs and consider future growth prior to purchasing a machine. A simple way of doing this is to run a usage report covering a three-month period for your facility. A good rule of thumb is to keep at least 80% of your fast moving medications in canisters and the rest as tray fills. Typically, the canisters would include chronic care medications, and your tray fills would consist of antibiotics, controlled substances, non-formulary medications, and other slower moving medications.
You should only consider a machine that affords the option of expansion, and allows you the flexibility to exchange canisters when medications are no longer being used. Generally, the more medications you can keep in canisters, the faster the packaging process will be with the least amount of staff necessary to operate the machine.

Managing Stock Outs or Discontinued Products
Often it can be difficult to balance one's budget and stock as it relates to packaging. While past purchasing trends are instructive, products may change based on the needs of the patient or prescriber. The following are key steps when managing stock outs or discontinued products:

• Run a monthly purchasing-history report from your wholesaler to determine approximate volume and usage
• Always ensure canisters are full and a back-up bottle is stocked
• If filling units on a scheduled basis, run a usage report a day or so before the scheduled run in order to obtain those medications from the wholesaler. Some packaging machines automatically send this information to the wholesaler once a report is created
• In the event that your wholesaler is out of a medication, ask if the medication can be obtained from another distribution site and be shipped expeditiously
• Change chronically short medications to other generics that are more consistently stocked

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Darby Kubik, RPhT
Automation Coordinator
St. Alphonsus RMC
Technology in use: Swisslog PillPick

Cleaning and Maintenance
Our pharmacy staff is responsible for basic cleaning and maintenance, so to avoid having one person perform this entirely, certain shifts are assigned specific duties (e.g., clear the rejects bin and sweep the floor inside the drug storage area) to complete daily. Users then sign a log to document any time spent on cleaning or maintenance.

Using Reports for Inventory Control
It is important to keep an up-to-date list of inventory in the packager. This list can be cross-referenced with the dispensing volume report for bin medications to help influence changes in those medications considered permanent or non-permanent. The volume report for all medications also is run and sorted by quantity difference to determine new medications to add or others to remove. The outdated medications are reviewed to remove or lower stock levels. We also review a report of medications that show no movement to change their status.

Handling a New Manufacturer
When we receive product from a new manufacturer, the old stock in the drug storage area is unloaded and the parameters are changed to match the new product. The old manufacturer information is deleted and the unloaded medications are placed in our manual pick, back-up inventory.

Calculating Inventory for the Future
One feature we would like to see in the future would be an inventory record on the medication parameters for back-up stock as well as what is currently kept in the drug storage area. By differentiating these entries, the robot could calculate overall usage and help determine reorder levels.

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John L. Feucht II, RPh
Director of Pharmacy
Mercy Medical Center
Technology in use:
McKesson PACMED

To get the most out of high-volume unit dose packaging operations, pharmacy should identify a core user group and train them thoroughly. At Mercy, pharmacists provide general oversight for packaging, and three highly skilled technicians have primary packaging responsibility with two additional technicians packaging as needed during evenings and weekends. Our state board of pharmacy mandates positive ID on packaging, therefore a pharmacist authorizes every canister refill with a badge scan and password, and then signs a manual report. Only then does the technician return the filled canister into the packager. Before a full packaging run, we test package one pill, which the pharmacist must check and sign off on. After sign off, the technician is authorized to complete the batch run for that medication. Then, the pharmacist will do a final check and sign the report.

Work with your vendor on feedback for the machine, as this feedback can lead to valuable efficiency changes. For example, the original robot-ready PACMED used a thin packaging material and a print ribbon. The packaging material was prone to curling and deforming over time while it was stored. This contributed to dropped packages by the robot, and so a thicker packaging material was developed to prevent deformation. In addition, it is always important to look for ways to reduce unnecessary consumables, so by introducing thermal printing with the new packaging media, we were able to eliminate the print ribbon. Lastly, it was valuable to us to work with our vendor's service team in developing a standardized guide that outlines the proper procedures for cleaning the machine and the frequency at which those tasks should be performed.