Renovating or designing a new pharmacy can be a daunting project for any facility to undertake, especially given the many moving parts and facets of design to consider. As medication safety experts, pharmacists may not have the same level of expertise with design issues, such as knowledge of ADA requirements or the ratio of prescription volume to shelf space in linear feet. To be successful in creating an effective pharmacy requires a collaborative process whereby pharmacy coordinates the expertise of architects, plant engineers, the IT department, and casework vendors while addressing the needs of pharmacy staff.
Capital Health in Mercer county, New Jersey serves as one of the region’s leaders in advanced medicine with significant investments in advanced technologies, including CyberKnife and the da Vinci robot. Prior to November 2011, Capital Health operated in facilities that were built over 110 years ago and it had become cost prohibitive to continuously update the physical structure as well as the technology within. The decision was made to design and build a new facility. Phase one of this new hospital is a 233-bed acute care, community, not-for-profit medical center with plans and capacity to expand further in the future.
Pharmacy Layout and Design
After the groundbreaking ceremony, pharmacy leadership held several meetings with the architects of the new hospital to ensure the pharmacy was built to accommodate the needs of the growing institution. It was ultimately decided to allocate 7,700 square feet to the 24/7 pharmacy in order to sufficiently serve the pharmaceutical needs of at least 350 patients. Designed to operate in a decentralized distribution model, 90% of the medications are dispensed from automated dispensing cabinets (ADCs) supported by carousels. Emergency and first doses are sent through the pneumatic tube system to their designated patient care areas.
With input from staff, the pharmacy management team designed the department based on the workflow of the pharmacy to ensure cohesive alignment of order processing and medication dispensing. Thus, this important and busy area of the department was placed in the front center of the pharmacy layout, with the carousel on one side and the IV cleanroom on the other. The pharmacy includes separate rooms for NICU and pediatric order processing and chemotherapy preparation. The offices, conference room, storeroom, and IV solutions storage area are positioned at the back of the department. Also incorporated in the layout is a break room and locker space. When designing these additional areas, it is critical to pay attention to legal requirements, such as the American Disability Act (ADA), which impacted the design of the restroom, the 34-inch height of the pharmacy window counter, and the sink.
Everything had to be clearly identified and marked in the plans, including the size of each work area and room, the location and size of each doorway, and the layout and design of every cabinet and desk. Despite this intense attention to detail in the planning stage, we still encountered challenges during the build, such as existing pipes and ductwork in the ceiling that necessitated the relocation of the carousel. Because budgetary constraints prevented modification of the design once it was finalized, it was important to get the design correct at the outset. Engage facility engineers and architects for their advice early in the process to eliminate any retrofitting after the project is complete.
Recommendations for Casework Installation
RMC had undergone a remodeling in the past that provided a knowledge foundation for designing this new pharmacy. Even with such previous experience, it is recommended to seek out expert advice in any remodeling or building of a pharmacy, as a design consultant or casework vendor has the capacity to foresee issues that may be unapparent to the inexperienced eye, and ensure a smooth workflow in the pharmacy.
We knew we had to ensure compliance with local ordinances and state laws, such as regulations governing the width between aisles, routes of egress, and the height of shelves and casework in relation to the ceiling. This was hard earned knowledge: The previous remodeling of the RMC pharmacy resulted in the need to reinstall the casework in order to pass inspection, causing a time delay as well as agony endured by the staff. Thus, it is important to research and review several bids from casework vendors prior to committing to a contract to make sure they are adequately qualified for the job. We chose the vendor for this project based on their strong reputation, product quality, and reasonable pricing.
Choosing the Correct Automation
Decisions need to be made in advance about technology implementations for a new pharmacy. Start by defining the dispensing and packaging needs based on bed size, patient population, and the chosen distribution model. For example, we chose to implement two large carousels as each can accommodate over 500 drugs from oral unit dose items to large injectable vials. The two carousels house over 95% of our non-refrigerated medications. The dispensing accuracy delivered by a carousel outweighed our facility’s need for an integrated packaging machine that would be used for packaging small amount of medications, thus we chose to invest in the carousels and rely on a tabletop repackager for repackaging unit dose medications in-house when needed.
Additionally, the decentralized distribution model of the pharmacy directed us to use ADCs on the floor and in the operating room. Because the Joint Commission deems IV solutions as medications, the pharmacy must maintain full control of their dispensing. Consequently, ADC towers were implemented to provide storage for all IV solutions, premixed antibiotics, bulk products, and individual patient medications. This approach also provides accurate usage tracking and billing of IVs. Keep in mind that the tower bins are identical, making it important to label each bin with the respective IV solution name to avert any confusion for nursing staff.
Our dedicated ADC administrator managed the ADC and carousel implementations, which eased the time consuming processes of planning and purchasing, configuring each pocket and cubie, verification, and finally delivery of medications to the appropriate patient care units on the floor. We budgeted 25 to 30 hours to setup each ADC, including the accompanying auxiliary ADC tower and refrigerator. The ADC administrator worked on similar medical and surgical units to reduce implementation time. An underestimation of time allotment can lead to disaster, thus it is recommended to have a dedicated automation expert on staff to handle the implementation, as well as run check-ups and software updates for the pharmacy systems.
Constructing an IV Cleanroom
It is important to size the <797> compliant anteroom and cleanroom appropriately to accommodate current and future compounding volume. Ideally, the anteroom should be large enough to allow staff to assemble all IVs and additives before proceeding to the cleanroom. For example, in our facility the anteroom is 576 square feet and the cleanroom is 198 square feet. In order to reduce the foot traffic into the anteroom, consider installing a refrigerator that can be opened from both the anteroom and the main pharmacy, and a pass-through opening with moveable racks to transfer plain IV solutions from the IV storage area into the anteroom. Additionally, including a glovebox in the anteroom enables evening and overnight staff to prepare one or two IV doses of medication without completely gowning up.
In our facility we designed a pass-through glass window between the cleanroom and anteroom that minimizes door openings, with a pressure monitoring device to ensure the rooms are under positive pressure at all times with air flowing from the rooms outward into the main pharmacy. We use horizontal IV hoods inside the cleanroom and a cart to bring in supplies. Note that any casework abutting a wall must be caulked to avoid any dirt accumulation.
Flexibility and Enhanced Workflow
After a year in operation, we are pleased with the new facility as the design provides flexibility for future growth and our staff appreciates the enhanced workflow. The environment is pleasing and definitely contributes to improved morale. The commitment from our administration and our casework vendor was invaluable to our success in creating this state of the art pharmacy. When choosing to engage in a pharmacy build or renovation it is strongly recommended to engage vendors and consultants who have extensive experience in pharmacy and cleanroom design. It is equally important to engage an architect, facility engineers, your IT department, and your facility’s pharmacy leaders in order to develop a successful department with improved workflow.
Chester Lau, MS, is the director of pharmacy at Capital Health Regional Medical Center in Trenton, NJ and Capital Health Medical Center at Hopewell, NJ. He received his BS in pharmacy from Rutgers University in 1976 and his masters in clinical pharmacy from St. Johns University in 1980.
Theresa Catalano-Christou, MS, is the pharmacy manager at Capital Health Regional Medical Center in Trenton, NJ and Capital Health Medical Center at Hopewell, NJ. She received her BS in pharmacy from St. John’s University in 1985 and received her masters in hospital pharmacy administration from St. John’s University in 1991.
Add an Employee Pharmacy to the Mix
While it may seem counterintuitive, building the new facility provided an opportunity for institutional cost savings. With the rising cost of drugs, our administration was searching for ways to reduce drug benefit expenses without imposing an extra financial burden on employees. We were able to deliver this by creating an employee pharmacy; we simply allocated an 850 square foot section from the main pharmacy to serve this purpose.
The employee pharmacy is open five days a week from 7am to 5pm and handles an average of 180 prescriptions a day for employees and their families. Prescriptions are processed for the two hospital campuses, three satellite locations, and include mail order when necessary. The employees appreciate the convenience and the reduced co-pay that the employee pharmacy provides. Most prescriptions that are dropped off or called into the pharmacy in the morning are available for pick up in the afternoon. An average of 75% of all employees’ and their dependents’ prescriptions are processed in-house, reducing the hospital’s drug expenses for employees.
To design a successful employee pharmacy, it is important to manage the area as a true retail pharmacy. For facilities with limited retail experience, your casework vendor may prove to be an invaluable resource. For example, our vendor recommended the appropriate linear feet of shelves with adjustable height features based on our prescription volume. Consider designing the department with more shelves than initially needed so that there is sufficient capacity to expand in the future. Some of the other design choices we made included adding adequate counter space for four staff members to work during peak hours. A pneumatic tube was also installed to deliver finished transactions. Additionally, we recently added another 22 cubic foot refrigerator with plenty of spare space. Our design provides a smooth workflow in the employee pharmacy, and ensures all prescriptions can be processed and completed in an efficient and safe environment.