Medication management in the unique environments of the operating rooms (ORs) and procedural areas presents challenges and opportunities for pharmacy. The medication-use process in the OR differs from other areas in the hospital in that few staff members outside of anesthesia providers work in the area, and thus it is not directly observable by others in the organization. Moreover, a large number of controlled substances are utilized in the OR, making medication security to prevent diversion a high priority. At the same time, sufficient access to medication must be maintained to ensure a smooth workflow.
In this distinct setting, it is critical that organizations develop a strategy to ensure safe medication use. Pharmacy should be involved in managing the use of high-risk medications, mitigating controlled substance diversion, and ensuring regulatory compliance. Automating the medication-use process in the OR by implementing automated anesthesia cabinets is one strategy that can improve medication management and security while preserving timely access to needed drugs.
United Hospital, part of Allina Health, a not-for-profit health system in the Twin Cities east metropolitan area comprising 13 hospitals, provides a full range of health care for more than 200,000 patients each year. United Hospital operates surgical services in multiple areas, including a main OR with 18 rooms, a two-room cardiovascular OR, three mother/baby OR areas, and a day surgery center with seven rooms. The main OR is serviced from Monday through Friday from 6am to 4pm by a satellite pharmacy that verifies procedural orders and prepares IV medications, supplying them to the ORs via a tray system. The United Hospital central pharmacy provides services for the OR and procedural areas after hours and on weekends. Medications are dispensed throughout the hospital using automated dispensing cabinets (ADCs) as the primary method of drug distribution, with approximately 80% of medications distributed via ADCs and the remaining medications distributed by one daily oral/bulk item cart fill and four IV batches.
Automating the OR Medication-Use Process
Several objectives influenced the decision to implement automated anesthesia cabinets in the ORs. In 2013, The Allina Drug Diversion Council completed a health system-wide gap analysis to identify challenges to drug diversion best practices. The ORs and procedural areas were identified as the number one risk area in the organization, and expanding utilization of automation and technologies was identified as a key risk mitigation strategy. Thus, preventing drug diversion in the anesthesia areas by implementing automated anesthesia cabinets became a central initiative for the organization.
Health care professionals are not immune to substance abuse and have greater access to medications than the general public. Among anesthesiologists, the rate of opioid abuse is greater than that of the general population and among physicians in general; nurse anesthetists also are at risk.1-3 Because automated anesthesia cabinets create a record of each transaction, controlled substance use can be tracked by user, which facilitates identification of anomalous trends.
Other important objectives that drove the decision to implement anesthesia automation included increasing medication safety, ensuring regulatory compliance, preventing financial challenges and decreasing waste, and improving inventory and drug shortages management. Given the significant volume of high-risk medications utilized in the OR, there is a strong risk for harm if these medications are not properly managed. Automated anesthesia cabinets securely store these medications, providing safe use while ensuring access. Moreover, automating OR medication management may increase charge capture (if the system is configured to charge), preventing financial challenges. Many medications used in the OR setting have significantly increased in price in recent years, making proper billing and inventory management increasingly important. Appropriate preparation and use of these products are crucial to ensure proper pharmacy stewardship of financial resources and reduce waste. Automating medication use in the OR increases medication oversight, improves inventory management and charge capture, and simplifies recordkeeping to support regulatory compliance.
Developing an Implementation Plan
Several months prior to automated anesthesia cart go-live, the pharmacy department partnered with anesthesia leadership to develop an implementation plan. Multiple issues needed to be finalized, including cart design and drawer configuration, procedures for controlled substance waste and documentation, workflow for restocking the carts, staff training requirements, and the level of go-live IT support required.
Designing the Cabinets
Determining locations for the automated anesthesia carts was based on anesthesia workflow. A cart was placed in each OR suite to replace the tray and manual cart system. Future goals include implementing automated carts in other procedural areas as well.
The primary OR pharmacist and technician were involved early on in the implementation process to assist with pharmacy workflow development and to work with anesthesia providers to design the medication drawer configuration. Working with anesthesia over several years, the OR pharmacist and technician had developed excellent relationships with the providers and were key assets to ensuring successful implementation.
Several factors were taken into consideration when configuring the carts, including medication safety, mitigating controlled substance diversion, and providing storage for large items and non-pharmacy materials. The cart configuration had to allow for the use of single-item pockets for controlled substance dispensing, which are beneficial from a workflow and diversion-prevention perspective, as they eliminate the need for complicated count-backs and ensure that only one medication is dispensed at a time.
In addition, the cabinet configuration needed to accommodate both medications and the supplies required by anesthesia for procedures. Anesthesia providers raised concerns about the amount of supply storage on the new carts. Previously, anesthesia utilized an entire cart to store supplies, with pharmacy items limited to a single drawer. With the new system, non-pharmacy supplies would be limited to three drawers (approximately one-third of the cart). By working with anesthesia leadership several months prior to go-live, we were able to accommodate storage of supplies on the automated carts by reducing the quantity of supplies and adding additional holders to the outside to attach additional storage.
Accommodating Large Items
Prior to implementing automated anesthesia carts, anesthesia providers obtained large items, such as albumin, from the OR satellite pharmacy on a daily basis and returned them at the end of the day if unused. Now, the albumin is stored in the OR in automated anesthesia carts. To accommodate larger items, some customization was required. One of the anesthesia material storage drawers was used to store the large size of albumin, a significant improvement over the manual process for albumin prior to automated cart implementation.
Training staff on the proper utilization of automated anesthesia carts prior to go-live is a crucial element of a successful implementation. Anesthesia staff requires hands-on experience using the cabinets in order to understand their functionality. By practicing with the new carts in various situations, staff was able to quickly become comfortable with the new process.
The switch from a traditional tray system to automated carts was not only a significant change for the anesthesia providers, but also for the OR staff. Anesthesia staff expressed mixed feelings about the change to automate the medication-use process in the ORs. The tray system had been utilized for many years, and staff was comfortable with the manual approach. Some providers had used similar automation when working at other institutions, while many were new to this technology. To obtain staff buy-in, pharmacy worked with anesthesia leadership to explain the benefits of the cabinets to providers; after learning the benefits of the automation, most anesthesia providers agreed it was preferable to using a manual system.
Training was provided via an online module that anesthesia staff viewed on their own schedules. In addition, several hands-on training sessions were provided in the weeks leading up to go-live; anesthesia providers were encouraged to ask questions regarding cart workflow and functionality.
Policies and Procedures
An automated cart restocking procedure was developed for pharmacy staff. Technicians found this process easy to implement, as it was similar to the process for restocking ADCs on the units. Bar code scanning of the medication drawer and the manufacturer’s NDC code on the medication was utilized to ensure accuracy.
Procedures also were developed for anesthesia waste disposal. Anesthesia providers are required to waste controlled substances with another licensed staff member and document waste electronically on the automated anesthesia cart at the end of the case. Adherence to this process is monitored by OR pharmacy staff and management.
Go-live was phased in over 3 weeks to allow onsite assistance during the conversion, which was critical as staff used the carts in multiple OR locations. The vendor, along with pharmacy staff, provided side-by-side support for anesthesia providers during the go-live period. Vendor support was provided from the early morning until most anesthesia cases were finished in the late afternoon.
Several lessons were realized through this experience. Perhaps most significant was recognizing the importance of all staff completing the entire hands-on training process. Some anesthesia providers attended only a portion of the hands-on training prior to go-live. Problems became evident during the implementation process and for several weeks following. While these providers eventually developed a comfort level with the new equipment and workflow, the change frustrated a few users. Ensuring all providers have adequate hands-on training time is essential for a smooth transition to an automated process.
Optimizing Automated OR Cabinet Use
The switch to automation has enabled the capture of a large amount of data detailing medication usage patterns and compliance with hospital policies and procedures. The next step is to optimize cabinet use by establishing regular inventory usage reviews, increasing diversion-monitoring efforts, and working with anesthesia leadership to ensure appropriate use of the equipment.
Ongoing drug shortages of critical anesthesia medications have increased the importance of evaluating usage patterns to ensure these medications are properly managed. When a shortage is identified for an item stored in a cabinet, locating all available product and determining the total quantity on hand is quick and simple, which facilitates decision-making regarding shortage management without requiring an extensive inventory counting process.
Ensuring accurate inventory levels in the automated anesthesia carts requires anesthesia providers to bar code scan each medication upon removal. This scan reduces the quantity on hand of the medication in the cart. In addition, bar code scanning verifies that the medication selected is correct, providing another layer of safety. Adherence to the bar code scanning process is essential for accurate inventory counts and increased safety. Pharmacy technicians regularly perform cycle counts to confirm inventory levels and identify areas where bar code scanning upon removal is not occurring. Pharmacy leadership then follows up with anesthesia leadership to provide feedback on areas of improvement.
Implementing automated anesthesia carts was an important safety improvement to the OR medication-use process at United Hospital. Automating medication management in the ORs has led to increased medication security, decreased diversion risk, and facilitates improved drug shortage management. Switching from a manual to an automated system requires a partnership between pharmacy and anesthesia in order to develop and update policies and procedures. As with any new technology implementation, ongoing optimization is required to maximize use on an ongoing basis.
Jay C. Christenson, PharmD, MS, BCPS, is the pharmacy operations manager at United Hospital, part of the Allina Health System, in Saint Paul, Minnesota. He received his PharmD from the University of Minnesota College of Pharmacy and completed a PGY1/PGY2/MS residency at the University of Kansas Hospital.