Stocking, securing, and providing rapid access to medication products used by emergency medical technicians, paramedics, and other pre-hospital providers is a challenge for many hospitals. From the pharmacy standpoint, ensuring the integrity of these products is paramount; as such, a mechanism must be available to determine the validity of the products. Has the product been tampered with? Is the product expired or close to expiration? Has it been adulterated in any way? The absence of an automated solution for storing medications and facilitating access leaves these issues unresolved. As the inpatient pharmacy is ultimately responsible for all medication products housed and dispensed during the course of patient care—whether that is within the hospital or outside—it is good practice to utilize an automated system to perform dispensing and reconciliation processes, and an ADC is ideally suited for this activity.
Provision of Products to PHPs
Reconciling and auditing facility-provided medications accessed by pre-hospital providers (PHPs), such as EMTs, is clearly an important element of emergency medical services. Although this can be performed in different ways, a common, manual approach is to provide the PHP with a standardized checklist form on which the PHP indicates all medication products taken from the facility and administered to a patient prior to that patient being admitted to the hospital. Their supplies are then restocked via the central pharmacy and the paper checklist is reconciled with the pharmacy’s dispensing record.
An alternative approach is to utilize an ADC that is located within the ED and dedicated specifically for PHP use. The PHP is given digital access to the cabinet with an ID number and is able to remove the necessary items and then indicate via the cabinet’s software all items administered and wasted. With this approach, pharmacy can easily perform an audit as needed and compare the medications the PHP indicates as accessed and administered or wasted against the ADC software to ensure access is not being abused.
The Value of a Dedicated ADC
There are many benefits to both the facility and the PHP in dedicating an ADC for emergency, pre-hospital use, not the least of which is convenience. Once the PHP arrives at the hospital and their patient has been admitted, he or she can quickly reconcile whatever product usage was necessary for the call via the ADC, restock any needed products, and be on their way. There is no need to fill out any hard copy forms that would require internal record keeping, nor does the PHP need to locate the central pharmacy within the hospital and wait while replacement products are dispensed before they can return to work. Furthermore, the inpatient pharmacy may not prioritize the replacement of PHP products, especially if there are other workload demands at that time, often requiring the PHP to wait until the workload lightens.
Eliminating the need for the PHP to rely on the inpatient pharmacy for restocking of medications creates a faster turn around for the PHP. Likewise, removing the responsibility for servicing PHPs from inpatient pharmacy’s daily operations helps streamline inpatient activities. With today’s modern ADC security and monitoring software, the hospital can easily track and audit who accessed the machine, when it was accessed, and what was removed.
Independent Inventory and Monitoring
Given the nature of its use, it is wise to segregate the inventory, stocking, and monitoring processes for an ADC dedicated to PHP service from other ADCs used in the hospital strictly for inpatient services. For one thing, the PHP is likely to require different products from what is usually stocked in an inpatient ADC, so a separate process helps minimize any unnecessary or cross access to medications. To enable this, PHPs should be assigned a different access code type than those used for inpatient ADCs. This limits the PHPs’ access to only those medication products available in the emergency department itself. Likewise, it is valuable to assign a dedicated pharmacy technician in the ED, who (in addition to their other tasks) will stock the ADC daily or based on need. This removes the risk of accidently providing a PHP with access to medications intended for use in treating a patient already admitted to the hospital or medications that are outside the PHPs purview.
Determining the appropriate products to house in the ADC dedicated to PHP use is an important first step. Begin by reviewing all medications that PHPs are authorized to administer according to their licensure in your state. The ADC stock should be limited to only those products licensed for use by PHPs servicing the hospital. Fortunately, the number of products used by emergency responders is not extensive. The most common products include IV fluids, resuscitative medications (such as atropine and epinephrine), antiemetics, and antihistamines. At the outset, in order to ensure the efficiency of the medication use process, it is important for pharmacy managers (particularly ED pharmacists) to meet regularly with PHP administrators in order to discuss utilization patterns and address any access issues. Over time, the pharmacy manager can simply review usage reports generated through the ADC to determine how best to maximize inventory.
Billing and Waste Accounting
Once a patient is brought into the ED by a PHP and is admitted into the system, the patient ID is available in the ADC software. When the PHP accesses the ADC for restocking, he or she indicates the medications used for the admitted patient, and the patient is then billed for those products used in the pre-hospital setting. For example, if a patient receives a bag of IV fluid and an antiemetic during transport to the hospital, the PHP would access the ADC, remove those same items to replace the ones used, and the patient would be billed accordingly.
As with all areas of medication use, waste is an issue in the emergency pre-hospital setting. There are instances when a medication is prepared for use with a patient, pre-hospital, but the product is never actually administered. If, for example, a PHP drew up an antiemetic but did not administer it to the patient, the PHP would fill out a waste report. Ultimately, the patient would not be billed for that antiemetic; rather, the PHP company would be financially responsible for that product. There is value in the hospital assigning the responsibility for that wastage to the PHP, as this incentivizes the provider to be prudent with the products used and to perform a thorough assessment of the patient at the scene before opening or preparing a product.
In the absence of a dedicated ADC used to house medications for PHP use, a facility may be obliged to stock and distribute emergency-use products from the inpatient pharmacy. Unfortunately, this distraction can contribute a significant amount of extra work to inpatient staff workloads and negatively impact productivity. Among the medication-use areas in a hospital that can gain clear benefits from ADC use, pre-hospital services should be given proper due diligence. Ultimately, a closely monitored ADC dedicated to PHP use will provide heightened convenience and security, shorter turn around times for emergency pre-hospital providers, and a streamlined inventory and billing procedure.
Daniel P. Hays, PharmD, BCPS, FASHP, has worked as an emergency department pharmacist and is the former director of the emergency medicine pharmacy residency program at the University of Arizona Medical Center in Tucson. He received his doctor of pharmacy degree from the University of Minnesota and is the past chair of ASHP’s emergency pharmacists section advisory group for the clinical scientists and specialists network.