Health systems continually seek cost-effective ways to manage drugs at all levels of the supply chain in order to create efficiencies, reduce costs, and increase medication safety. Automating manual processes can help reach many of these objectives. For example, automating the refilling and deployment of emergency drug trays from a central hub to multiple locations within a health system can increase patient safety and improve workflow.
UNC Health is a not-for-profit, integrated health care system owned by the state of North Carolina and based in Chapel Hill. The health system currently comprises UNC Hospitals and its provider network, the clinical programs of the UNC School of Medicine, and eleven affiliate hospitals and hospital systems across the state. In 2018, UNC Health recognized an opportunity to leverage its Shared Services Center (SSC) to standardize and centralize the replenishment and distribution of emergency trays and medication kits, with the goals of ensuring medication safety and realizing significant operational benefits. The SSC supports pharmacy supply needs to UNC Health entities through the integration of pharmacy purchasing, distribution, contracting, sourcing, and inventory management.
Developing a New Strategy
Refilling emergency trays in the pharmacy can be a time-consuming, error-prone task. Not only is the process exceedingly repetitive, but there is an inherent risk of error in a manual restocking model, and medication-use metrics can be difficult to quantify when using this approach.
Prior to our implementation of an RFID tray management solution, each entity in the health system managed and processed its own emergency drug trays for distribution throughout their respective facilities. Technicians and pharmacists utilized a manual replenishment process to refill used items and remove expiring medications. This approach was burdensome and rife with the possibility of error; it also took pharmacists away from clinical responsibilities. Pharmacy leaders saw the process of automating tray refilling as an opportunity to ensure medication safety, achieve process improvement and standardization, and free up pharmacist time for value-added activities.
Implementing a standardized process within a central distribution (hub-and-spoke) model required two strategic initiatives:
To guide workflows, an RFID medication management technology was chosen and implemented. The solution uses bar code scanning when a local site receives a tray from the SSC to track change of ownership. SSC leadership approached each of our health system’s eleven hospitals and explained our objective of centralizing and standardizing the tray management process; after consideration, seven hospitals opted to participate in the program. The other four hospitals decided not to implement at the time for various reasons, mostly related to competing initiatives and projects. In addition, two of these hospitals were already using RFID technology for tray management.
Health system-level initiatives at UNC Health are always proposed and approved by the health system pharmacy and therapeutics (System P&T) committee. This committee includes pharmacy leaders representing each hospital, physician leadership, the vice president of pharmacy, and several stakeholders from the SSC. After approval from the System P&T committee, plans and project details were communicated to each of the participating hospitals.
Given the importance of gathering input from each local hospital for the tray layout standardization effort, the system project-planning model was flipped and a clinical workgroup was formed with representation from each participating hospital. This group was charged with developing a proposal for a standardized emergency tray layout and pursuit of final approval by the System P&T committee.
The group began reviewing emergency tray drug inventory data and evaluating opportunities to consolidate drugs, strengths, and dosage forms. An aggregated list of all medications stocked on emergency trays across all hospitals was created; this list contained 47 unique drugs. The first phase of the project compared the drugs across all hospitals and addressed drugs considered non-essential, either clinically (ie, minimal use in Advanced Cardiac Life Support [ACLS] guidelines) or operationally (ie, drugs that could be relocated to an ADC). The result of this first phase was the removal of 27 drugs from the aggregate list.
Thereafter, we reviewed the finalized list of drugs, with discussions focused on further consolidation of concentrations and package sizes. For example, all seven hospitals used dopamine preparations, but in four different concentrations and sizes; after discussion, the group chose a single concentration and size as the standard.
The focus of the final phase of the discussions was to arrive at a universal par level of each drug in the standardized code tray. If the choice was between a lower par and a higher par, the higher par was initially chosen to ensure that each hospital’s needs were met. During this time, the group also noted that the RFID medication management technology would provide analytics pertaining to the actual use of each drug at each hospital, and that usage reports generated by the RFID technology would better inform our choice of appropriate pars in the future. When the clinical work group came to its final consensus on the contents of the standardized code tray (see FIGURE 1 and TABLE 1), its recommendation was presented to and approved by the System P&T committee.
As the standardization process unfolded, we saw the opportunity to both increase efficiency with the central distribution process and provide access and insight into key drug inventory data in the code trays by using the RFID medication tracking technology. Our chosen RFID vendor was experienced and had the flexibility to accommodate the unique hub-and-spoke project approach. In addition, they were committed to integrating new features that we deemed necessary for multiple hospitals in the central distribution framework. For example, the system allowed for health system vs local site visibility and user access, as well as functionality that showed change of ownership of a tray when the tray is received at a local site. We worked closely with the vendor to coordinate the planning and execution of the new central code tray process with each of the local facilities.
The Implementation Process
After standardizing the trays, we turned our attention to implementing the technology throughout the health system. The SSC team accommodated each hospital’s project capacity and competing priorities in determining the project dates and timeline.
An implementation team was formed at each local site. These teams included representation from pharmacy, central supply distribution, the medical emergency resuscitation committee, and the local P&T committee. Each team discussed project timing and details prior to implementation.
To convert the hospitals to the central code tray distribution process, we worked with the SSC to establish the RFID medication tracking solution equipment at the hub, and then train the staff at that location. The SSC created a dedicated space for emergency tray processing that included sufficient high-density shelving to maintain large drug inventory quantities. As the replenishment model required physically moving emergency trays to each hospital, the SSC also purchased several heavy duty carts to facilitate tray shipping.
When implementing the new process at the local hospitals, SSC staff and the vendor deployment team ordered the required drugs for the code trays, placed RFID tags on each of the medications, and filled the code trays in accordance with the standardized layout. Pharmacists and technicians working at the local hospitals were trained on tray management procedures, including receipt of new trays within the RFID software, updating a tray’s location during dispatch to a code cart, and return of trays back to the SSC. For example, users must scan a bar code on each tray and then select the correct intra-hospital deployment location to ensure proper delivery.
The new operational flow for tray replenishment is presented in FIGURE 2.
Within the first 3 months after the SSC was operational with the RFID medication tracking system, three hospitals implemented the new centralized emergency tray distribution model. The first implementation was at two of our smaller facilities: a 150-bed satellite campus and a 25-bed critical access hospital. Implementing at smaller sites created an important pilot environment for testing of critical operational steps in the replenishment process, with a low risk of disruption to patient care. The experience gained through this process facilitated successful system implementation at the 900-bed UNC Medical Center in the following months. An affiliate hospital implemented next, and our second-largest hospital currently is scheduled for implementation in 2020.
Cost Sharing and Allocation
Establishing any centralized service requires cost modeling that is equitable and transparent. For this project, the SCC maintains responsibility for all pharmacist and technician labor to replenish emergency trays. Participating hospitals are responsible for the cost of replenished drugs, consumable RFID tags, and a standard processing fee (see TABLE 2).
Due to proper planning and robust management, automating the workflow for emergency tray replenishment was a success. Strong project leads at the SSC, the RFID technology vendor, and each local hospital helped ensure a positive outcome. Although there were some initial challenges with the process, such as missing trays in deliveries, time and experience with the process eliminated these issues. Several “buffer” trays are stored as backups at the local hospitals to provide coverage in the case of a delay in shipping. The buffer quantity is determined by local pharmacy leadership and central supply staff, and is a relative percentage of the total number of trays in circulation.
Usage analytics from the RFID medication management system inform our purchasing to fine tune par levels and avoid the risk of a medication stockout. The analytics are reviewed on a weekly basis and used to measure drug utilization velocity, particularly for the fastest moving medications.
Moreover, shifting code tray processing from the local hospitals to the SSC has proven to be a repeatable process. For example, it can be replicated to introduce other types of trays or kits, as well as accommodate other current or future members of the health system.
Through careful planning, adept project execution, and cooperation with a vetted technology partner, UNC Health has improved medication safety while driving operational efficiencies. We used the existing distribution infrastructure to improve a process that decreases task redundancies and leverages the economies of scale of the system-level supply chain.
Use of the RFID system has allowed us immediate, comprehensive data insight into emergency tray medications at participating local hospitals. Data visibility has helped streamline management of expiring and recalled drugs. Moreover, implementation of RFID technology to guide tray replenishment has led to process standardization and a reduction in medication errors. Most importantly, to date, there have not been any medication errors (ie, incorrect drug, drug quantity, or expired drug in a tray) associated with the automated emergency tray system.
Kriss Petrovskis, PharmD, MS, is a pharmacy manager at UNC Health. He completed a 2-year residency in health-system pharmacy administration at the Nationwide Children’s Hospital and both Doctor of Pharmacy degree and MS in health system pharmacy administration from The Ohio State University College of Pharmacy. Kriss’ professional interests include practice management, resident education, supply chain and 340B, drug shortage management, pharmacy automation integration, and centralization of pharmacy services.
Daniel Schenkat, PharmD, MS, is an assistant director of pharmacy at UNC Health. He received his Doctor of Pharmacy degree and MS in health-system pharmacy administration from the University of Wisconsin School of Pharmacy. Daniel’s practice interests include pharmacy leadership, automation and technology, data analytics, and pharmacy technician role advancement.
Matt Lamm, PharmD, MS, is an assistant director of pharmacy at UNC Health. He received his Doctor of Pharmacy degree and MS in health-system pharmacy administration from the UNC Eshelman School of Pharmacy. Matt’s practice interests include pharmacy leadership, utilizing Lean Methodology and the Value Management System, advancing practice models in community hospitals, and being a preceptor for pharmacy students and residents.
Drug Shortage Management
Throughout 2019, drug shortages occurred for almost every emergency syringe, prompting the FDA to take action by issuing extended dating on these products. Working under the assumption that drug shortages would be inevitable moving forward, our health system leveraged its existing drug shortage management committees to implement mitigation strategies for drugs included in the emergency trays. This strategy included active management of the drug supply, frequent input from the pharmacy purchasing team, and ongoing review of emergency drugs on critical shortage. The RFID technology’s embedded analytics provided valuable information on drug quantities and expiration dates. This insight helped drive strategic decisions on maintenance of drug inventory.
The Shared Services Center pharmacy intentionally chose to maintain a 2-month supply of all emergency tray drugs. This decision mitigated the risk of a drug shortage impacting the emergency tray contents, as well as its downstream effects, including needing to make changes to an emergency tray across multiple hospitals.
It is important to note that our maintenance of a larger central inventory allowed local hospitals to reduce emergency tray inventory stock.