Refilling anesthesia trays in the pharmacy for delivery to the ORs can be cumbersome and time-consuming. Not only is the process exceedingly repetitive, but using a manual restocking model is rife with opportunities for error, and medication use metrics are difficult to quantify.
In a hospital with a high volume of OR patients each day, the tray management process often requires a significant time commitment from pharmacy technicians. Automating tray replenishment can increase efficiency, eliminate errors, and optimize workflow. According to Pharmacy Purchasing & Products’ 2018 State of Pharmacy Automation Survey, pharmacists who have implemented automated tray management systems rate them favorably; 89% deem their systems to be good or excellent.1
Northwestern Memorial Hospital (NMH) is an academic medical center in Chicago, Illinois, that partners with Northwestern University Feinberg School of Medicine to provide quality, cost-effective, patient-focused care, as well as an environment of academic inquiry and innovative research, including the opportunity to participate in clinical trials. US News & World Report ranks NMH the top hospital in Illinois and among the top 25 in the nation in 11 adult specialties, including cardiology and heart surgery, neurology and neurosurgery, and cancer.2 With more than 70 ORs used to perform over 100 surgical cases each day, ensuring that providers have quick access to the necessary medications for each case is one of pharmacy’s top priorities.
Automating OR Tray Management
Historically, NMH had utilized a manual tray refill process in the OR satellite pharmacies. However, given the significant number of OR cases each day, and with the volume steadily increasing, pharmacy was spending an inordinate amount of time counting par levels, checking expiration dates, and refilling OR trays, all of which took time away from other critical duties. In addition, the manual restocking process presented significant room for error. Thus, when an automated, RFID-enabled tray management system became available in the marketplace, we investigated the utility of this technology.
The tray management system vendor visited the hospital to conduct live demonstrations of the replenishment system to illustrate the value of the technology to pharmacy and OR stakeholders. The system uses RFID tags to track every medication used in the tray. The tags are applied to each vial, syringe, and bag. When a used OR tray is received in the pharmacy for restocking, it is placed in a scanning station where each tag is automatically scanned; thereafter, a report is generated that specifies which medications must be replenished, are expired and must be replaced, or are incorrect. The pharmacy technician restocks and rescans each tray; if each component is correct, the report is complete and the refilled kit is sent back to the OR.
Upon watching the demonstrations, it quickly became clear that the system would significantly increase the accuracy of tray replenishment, prevent issues with expired medications, and reduce the time required for technicians to refill trays. We ultimately made the decision to implement the system specifically for the purpose of managing the OR tray replenishment process. After highlighting the safety and efficiency benefits of the tray management system, our positive relationship with anesthesia helped us gain their buy-in for purchasing and implementing the technology. Due to our large volume of trays, in 2017 we purchased two systems for use in our facility.
Building the Trays
Pharmacy provided the vendor with complete medication content information for all of the OR trays currently used at NMH, and the vendor’s team built those specifications into the system. After the trays were built, pharmacy worked collaboratively with anesthesiology to adjust the medication quantities and locations to best fit OR needs and workflow, and made these changes to the tray layouts. The trays are organized in a linear manner designed to follow the order of the case; all the medications are organized from left to right, matching the anesthesiologist’s needs from the start of surgery through the end of the case (see FIGURE).
Once the tray layouts were finalized and physically built, the vendor’s team spent a week in the hospital to assist with troubleshooting during the go-live. The implementation process progressed smoothly, largely due to the extensive, hands-on training provided by the vendor.
Dedicating Resources to Tray Management
Identifying a staff member to assume ownership over the OR tray replenishment process was a critical factor in our success. The technician specialist designated by NMH for this task received comprehensive training to ensure mastery over tray management, and is charged with overseeing inventory, ordering necessary supplies, and running reports.
Because the system itself and the necessary auxiliary supplies require sufficient space, we designated a small room adjacent to the main inpatient pharmacy to accommodate the two tray management scanning stations as well as supply storage (see PHOTO). The main benefit of utilizing two tray systems is that it allows two technicians to fill trays at the same time, facilitating a fast turnaround. Designating a space and assigning a technician specifically for OR tray management has proven critical to maintaining the efficient workflow necessary for producing large numbers of OR trays on a daily basis.
After implementing the OR tray management system, we significantly increased our efficiency by adopting a tech-check-tech (TCT) process. The TCT process was incorporated into tray management at the tagging step. TCT-trained technicians verify that the product (eg, vial, syringe, etc) matches the RFID tags. Once verified, the tagged products may be used to stock the trays. The TCT program permits a certified pharmacy technician to check the work of another technician rather than requiring a pharmacist check. TCT is not prohibited in the state of Illinois, and pharmacy leadership determined that using TCT for the OR tray management system did not require any additional approvals.
Because we already use TCT for various processes in the inpatient pharmacy, implementing TCT for the tray management process was a logical next step. For example, at NMH, specially trained pharmacy technicians check cart fill medications and ADC refills. TCT technicians must meet the following qualifications:
To achieve additional efficiencies, we rely on a 503B compounder to provide pre-filled, pre-tagged syringes, when possible, in order to alleviate technician time spent on verification and tagging processes. In OR tray management, TCT is used when we receive vials that are not already RFID-tagged; a technician enters the information into the system, prints the label, and attaches the tag to the product. Their work is then verified by another technician. Utilizing TCT during the OR tray replenishment process has helped ensure tray accuracy while improving efficiency.
Although the implementation went well, we experienced drug shortages that impacted OR medications. Our 503B manufacturer could no longer supply a sufficient volume of rescue medications, such as phenylephrine and ephedrine. Thus, pharmacy and anesthesiology stakeholders met to identify strategies to address these shortages and determine the best approach moving forward. A decision was made to include only one of the impacted medications in each tray; once that rescue medication had been used, the practitioner would have to retrieve another from the satellite pharmacy. One of the benefits of the OR tray management system is that it allows for the temporary use of different par levels, which supports a rapid response to shortages and then allows us to revert to the original par levels once the shortage is resolved.
Robust reporting capacity can help streamline shortage and recall management, and the OR tray management system has the capacity to run a variety of customized reports. For example, during the drug shortages, we requested reports detailing use of the medications on shortage. Access to that data allowed us to review and discuss usage with anesthesia leadership and identify a plan to decrease their usage to a specified amount. Similarly, if a medication included in the trays is recalled, the technician specialist runs a report to locate and remove those medications. In addition, the technician regularly runs medication use reports to continually fine-tune par levels, as well as tray-filling time reports that monitor the impact of par level adjustments on the technician’s time.
The benefits NMH has experienced as a result of adopting the automated medication tray management systems are twofold: time-savings result from the more efficient workflow and the capacity to track medication is enhanced. In comparison to the manual tray refill process, the automated solution saves numerous hours and ensures that expired and recalled medications are promptly removed from kits when indicated.
Moving forward, we are considering expanding the tray management system to manage drugs in our emergency response bags and airway bags, which also require expiration date and recall tracking. Ideally, our hope is that RFID technology will continue to evolve and will one day offer the ability to track high-cost medications throughout the facility. While manual processes will remain necessary in hospital pharmacy, new automation options can significantly increase efficiency, ensure accuracy, and protect medication safety. Keeping abreast of such new technologies is prudent for hospitals of all sizes.
Rachael Fleagle Miller, PharmD, MS, is the pharmacy practice coordinator for Northwestern Medicine in Chicago, Illinois. She received her Doctor of Pharmacy from the University of Cincinnati James L. Winkle College of Pharmacy and an MS in health-system pharmacy administration from the University of Wisconsin—Madison. Her professional interests include advancing technician practice, pharmacy operations, and pharmacy technology and automation.
Kristen E. March, BS, PharmD, BCPS, is the pharmacy manager at Northwestern Memorial Hospital in Chicago. She received her Doctor of Pharmacy from Midwestern University, Chicago College of Pharmacy, in Downers Grove, Illinois, and then completed a pharmacy practice residency at Northwestern Memorial Hospital. Her professional interests include OR operations, investigational drug services, critical care, and regulatory compliance.
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