For many hospital facilities experiencing growth in both patient population and physical plant, entirely centralized pharmacy operations can be a hindrance to efficient workflow. If a facility is growing its physical plant or adding ambulatory services, maintaining the ability to spread out certain tasks, such as compounding medications for specific services, can be particularly advantageous. Likewise, depending on the layout and location of the central pharmacy in a hospital complex, the decision to design, build, and integrate a cleanroom into pharmacy workflow can create financial and logistical challenges. Obtaining capital budget to contract with designers and builders, and purchasing all necessary fixtures and equipment for a new cleanroom can be daunting enough, but there are other compelling reasons why a hospital may decide a centralized cleanroom is not the ideal option for compounding operations.
At St. Joseph’s Regional Medical Center (SJRMC)—a 651-bed, academic tertiary medical center located in Paterson, New Jersey—we have found advantages to working with compounding isolators, including flexibility when it comes to layout, upgrading, and staffing our compounding operations. For these reasons, we perform our compounding in ISO Class 4 glove boxes.
At SJRMC, a state-designated trauma center that provides a significant amount of charity patient care, we compound roughly 95% of our IVs in-house. Products such as large and small volume IV doses of antibiotics, electrolyte replacement therapy, inotropes, and cardiac drips are always compounded in-house. Conversely, we always outsource our TPN and PCA IV products. As most hospitals have been attempting to do in recent years, we aim to purchase all of our oral and inhalation medications in unit dose when available. However, if those products are not available, we have to prepare them ourselves, and doing so increases costs and overall workload. As shortages and stock-outs of unit dose products are becoming the norm, we estimate that we prepare and package a total of approximately 30,000 doses per month due to these conditions.
In the central pharmacy at SJRMC, the main IV room houses three glove boxes, including one specifically designed for chemotherapy and other hazardous IV medication preparations. Outside of the central pharmacy, there are two glove boxes located in our critical care satellite pharmacy and one in our pediatric satellite pharmacy. During the course of the day, three IV batches are produced—one on each shift. Likewise, we perform bulk batching for some of the outpatient areas, such as the cardiac catheterization lab and the vascular lab, during the night shift.
Managing Compounding Workflow
All medication orders are received via our electronic medication order management system, whether in the central pharmacy or in the satellite pharmacies. When the system receives a STAT order, it is flagged in red on the pharmacy screen, thereby allowing compounding pharmacists to prioritize the order queue and process those STAT orders immediately.
As with any medication compounding, there is a specific process for bringing items in and out of the IV room, as well as in and out of the glove boxes themselves. For example, all medications are removed from their packaging in the main pharmacy because we do not allow cardboard into the IV room. Once inside the IV room, the vials or bags are placed in the antechamber of the chosen glove box where they are sprayed and wiped with alcohol before they are transferred into the compounding area.
SJRMC practices a decentralized compounding staffing model, allowing our pharmacists to move between compounding responsibilities and the patient care areas as workload permits. Enabled by this model, each satellite pharmacy manages the compounding needs of its patient population. On any given shift, a pharmacist will sign into a particular work group in our system and only see orders for the floors that group is covering. Thus, the critical care satellite services the critical care unit and the pediatric satellite services the children’s hospital. Pediatric and CCU orders are directly transmitted to their respective satellite pharmacies where they are checked and compounded.
During the day and evening shifts, the satellites are open to serve their respective areas. However, during the night shift, all medications are prepared and sent out from the central pharmacy. To assist this practice, we run velocity reports from our pharmacy system to determine what medications need to be stocked in each area based on use. The ordering of supplies and medications is a process centralized in the main pharmacy. The satellite pharmacies then stock from the main pharmacy and notify the buyer if reorders are needed. We also have established par levels for the majority of our medications to avoid excessive stock.
Focused Compounding Training
At SJRMC, we take compounding education very seriously, thus, all new employees receive one-on-one training by being paired with our most experienced IV technicians. Ongoing compounding competency is thereafter repeated annually for all existing staff. During the training process, we follow a checklist to ensure all aspects of aseptic technique and proper compounding tenets are covered (see Figure 1). Upon completion of training, the senior IV pharmacist signs off on the checklist or reassigns tasks based on demonstrated competency. In addition, we have new employees review didactic videos on aseptic technique and chemotherapy compounding safety. After viewing the videos, all compounding technicians are required to complete a written test. Lastly, each employee demonstrates their ability to safely and aseptically compound an IV dose using a growth media personal aseptic technique test. Again, the senior pharmacist reviews the results and if a technician fails any part of the process, he or she is re-evaluated and must retake the test to establish competency and proficiency before being permitted to compound.
All of our technicians are expected to rotate and train in all positions in the pharmacy over time, including the satellite pharmacies. Accordingly, we do not have designated compounding, central pharmacy, or transport technicians. Rather, our technicians rotate through the schedule and staff in different areas throughout the month, spending roughly one week at a time in any given area. All of our technicians must be registered and are required to become board-certified within one year of hire.
Moving Pharmacists to Patient Units
In some cases, remaining beholden to a fixed compounding location in the pharmacy is not conducive to that pharmacy’s workflow. Although we have considered centralizing compounding at SJRMC, the pharmacy and hospital administration agree that glove boxes are mobile and permit flexibility in facility design changes and modifications, elements that fit our medication distribution model.
Regardless, we are constantly striving to upgrade our systems and acquire new automation, thereby allowing our pharmacists and technicians to focus more on direct patient care, rather than manual labor tasks. Our goal is to have a pharmacist or technician make contact with every patient at some point during their stay at SJRMC. With this in mind, our mission is to increase the efficiency of our current staff, as well as increase medication outsourcing to instill this mission. Maintaining a decentralized compounding operation is a key factor to realizing our overall goals.
Michael Cairoli, RPh, MHA, is the pharmacy manager at St. Joseph’s Regional Medical Center in Paterson, New Jersey. He received his BS in Pharmacy from University of Connecticut and his master’s degree in health care administration from Seton Hall University. Michael completed his pharmacy practice residency at The Valley Hospital in Ridgewood, New Jersey. With a professional focus on pharmacy operations, investigational studies, and medication safety, Michael also is the state treasurer for the New Jersey Society of Health-system Pharmacists.
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