Errors in the preparation of compounded IV products are frequently reported to the Institute for Safe Medication Practices (ISMP), which recommends technology solutions—including bar code scanning of ingredients and volumetric/gravimetric verification of drug and diluent volumes—to help decrease compounding errors.1 Several studies have evaluated the impact of IV workflow management systems on reducing compounding error rates.2-4 According to Pharmacy Purchasing & Products’ 2020 State of Pharmacy Compounding survey, this technology is utilized at 52% of sites with 400+ beds.5 The process of implementing IV workflow management software at a large, multi-hospital health system with diverse service lines and existing pharmacy automation solutions is described herein.
The AdventHealth Orlando region houses eight inpatient facilities ranging in size from approximately 160 to 1400 beds. One of the facilities is a dedicated pediatrics facility, and pediatric patients are also treated at many of the adult facilities. In addition to the inpatient facilities, the health system includes six outpatient infusion centers and a centralized fill pharmacy. All facilities share a formulary, EHR, ADCs, and central pharmacy inventory management system. When considering our health system’s existing automation systems, large range in facility sizes, and diverse service lines, many factors had to be taken into account when choosing and implementing an IV workflow management system.
The Selection Process
Our informatics team is made up of three full-time pharmacists, one part-time pharmacist, one PGY2 resident, one part-time pharmacy intern, and one full-time pharmacy technician. The IV workflow project was led by our PGY2 resident with support from one of our pharmacists; decisions regarding build opinions were shared by the group. In choosing an IV workflow system, the informatics team created a request for information to determine the best fit. The features we chose to prioritize in a system included a dose queue, gravimetrics option, as well as the system’s reputation and time on the market.
Having experienced success with our inventory management software’s queue-based system, we sought to expand this workflow method into our compounding areas. Instead of being prompted by labels coming from a printer, the goal was to have all doses prioritized via queue to ensure up-to-date knowledge of what should be completed next via a simple-to-use interface. This would reduce the need to utilize multiple printers for different types of doses and minimize wasted time and movement sorting and searching for specific doses. From the queue, the team would be able to determine the best dose to prepare next and could remain at their hoods to do so.
When we began the process of evaluating the various IV workflow management systems, we were mainly familiar with systems that were based on the use of bar code scanning and volumetric checking. Bar code scanning of both medications and diluents is commonplace in hospitals with BCMA at the patient’s bedside. Utilizing bar code scanning in the compounding area allows us to also ensure the right medications are utilized for our compounded products. Volumetric checking uses photographs taken in the hood during compounding to ensure the correct volumes of diluent and medication are used to produce the right dose of a compounded sterile product.
The addition of gravimetric analysis allows us to take the amount checking properties of volumetric analysis and ensure that the right medication has been used in the preparation. By utilizing the specific gravity of the medications, we ensure the similar-looking translucent products being injected are correct and within the tolerances for amount. Our strategy was not to use the IV workflow management system for all doses but for specific high-alert medications and/or controlled medications where employing an extra check would significantly reduce error rates.
An Experienced Vendor
Working with a vendor established in the area of IV workflow was important to the team and to the organization. Given the variety of hospitals that would be serviced by the IV workflow solution we wanted to work with a team experienced in implementing systems at institutions of all sizes and for all disciplines so that as we continued on our implementation journey we could exchange questions not only with the vendor but also their vast network of other customers. In fact, before choosing the vendor we solicited opinions from various organizations with IV workflow software to understand their workflow processes and the benefits and limitations of the various systems.
The Implementation Process
Significant standardization prior to implementation was key to the IV workflow system being integrated as a comprehensive, region-wide solution. Multiple decisions had to be made, including the following:
Dose Types to Include
The initial consideration was determining the types of doses the IV workflow system would be used to dispense. Some health systems we networked with reported using their IV workflow systems for ready-to-use products, such as IV premixes, to take advantage of the bar code scanning and dose queue features. Because our central pharmacy inventory management system already utilized these features, the decision was made to use the IV workflow system for IV compounded doses and patient-specific oral liquid doses. This strategy would also ensure proper management of pharmacy inventory, as product is automatically decremented from stock as doses are dispensed.
We discovered that many products had to be rebuilt in our EHR system to align with standard dispense types and with standard naming conventions to facilitate a region-wide IV workflow management system solution. This was especially true of products used for pediatric patients. IV compounding practices at our pediatric hospital include preparing dilution products in advance and freezing/thawing to maximize beyond-use dating. This practice does not occur at the adult facilities that treat pediatric patients, where instead a smaller dilution would be made per patient-specific dose and the remainder discarded. Thus, a method to enable both processes using the same entries in our EHR system had to be developed. Understanding these intricacies required extensive collaboration with pharmacy leadership at our pediatric hospital, leading the way for standardization of pediatric dose preparation while also allowing some flexibility for the adult facilities.
A feature of the IV workflow system we implemented is tracking vial-sharing and auto-assigning beyond-use dating to facilitate cost reduction. In an era of extensive drug shortages, we wanted to use this feature to maximize use of high-cost single dose vials as well. Single dose vials are built in our EHR system to charge for the entire vial, and so a rebuild was necessary to be able to charge per lowest billable unit to enable vial sharing. An evaluation was completed to determine which products would have the highest impact if shared, but were also ordered often enough that the remaining drug in the vial would not expire before preparing the next dose. The only drug that fit these criteria was daptomycin, which if shared would save the health system an estimated $1.2 million annually. Thus, daptomycin was rebuilt in the EHR to charge per lowest billable unit and enable sharing vials between multiple doses.
Some of the preparation work that went into facilitating standardization ultimately exposed previously unknown or unreported issues with current compounding practices in relation to the EHR. By visiting the various campuses and discussing the current workflow, we were able to find and correct many of these issues. Barriers we identified included duplicate compound builds found with various recipes, campus dispensing processes with labels being printed to incorrect printers, and inefficient batch times. Additionally, issues were identified regarding pharmacist processes that had historically been done incorrectly but would work in a facility without an IV workflow system. As we transitioned to an automated environment with guardrails and safety checks, the way medications were profiled in the EHR system became just as important as the way they were prepared in the IV room itself. Selecting the right products in the EHR system and checking if the total volume of the dose should be adjusted is now of utmost importance, as this affects the dose preparation procedure presented to the compounding technician.
Thus, providing order entry energizers to the pharmacist staff became a mainstay of our staff training plan. Leading up to go-live we ensured the staff was well-educated about the overarching workflow changes by providing them information during energizers. Training for all IV personnel and pharmacists occurred within 2 to 4 hour sessions for every team member utilizing the hardware. These sessions were performed with both vendor and informatics support to ensure broad and specific questions could be answered. Training sessions were supplemented with handouts that included information detailing how to use the new software. As we started using the new system, the pharmacy informatics team was present during energizers to review any issues that were reported throughout the past 24 hours so that everyone was aware of how to resolve these concerns should they reoccur.
A decision was made to implement the IV workflow system on a site-by-site basis so that we would be able to provide dedicated support for training during each facility’s go-live. With other application implementations, we had received feedback that the evening and overnight shifts sometimes had questions or issues that they were not able to resolve without further follow up from our team. As the implementation of an IV workflow system would be the most significant workflow change in the pharmacy in some time, the informatics team was dedicated to remaining available for our technicians and pharmacists at all hours onsite. This way, troubleshooting could be completed by one of our team members immediately, increasing the staff’s overall engagement and ownership of the process change.
For each go-live we provide a week of onsite, 24/7 support and another week of extended onsite support crossing all three shifts. The reception of the IV workflow software system has been tremendous, and we believe adoption by all three shifts was driven largely by the extra support they received. Over time we have adjusted our schedule to increase support coverage for the overnight shift.
Although we were able to resolve many roadblocks prior to implementation, there were a couple of issues that presented during implementation. Our current EHR system requires a complex build for titratable products administered with a normalized rate—strength per unit of time. This complexity did not translate well to the IV workflow system, especially for pediatric doses. The IV workflow system offered a solution; however, it required that the dose ordered be the same every time. This solution worked for adult doses, as the products could be standardized; pediatric doses, however, posed an issue. Since IV pediatric doses are administered via IV syringe pumps, the size of the syringe that the dose is administered in must be adjusted depending on the rate of administration. Thus, the dose and volume are ever-changing and the solution the IV workflow system offered would not solve the issue at hand for pediatric doses. Because our health system is in the process of transitioning to a new EHR system that will resolve this issue, we are not currently pursuing a solution for these doses.
The IV workflow system selected offers preparation of patient-specific, oral liquid doses as well. Without the IV workflow system, many technicians can work on preparing a batch simultaneously; however, implementation of the system slows the process as only one technician can prepare one dose at a time. To alleviate this challenge, labor restructuring and batch times will be adjusted to maximize the process for oral liquid doses prepared through the system.
Many safety benefits were realized after implementation of the IV workflow system. The addition of bar code scanning ensures that the correct products are used to prepare the dose. If an incorrect product is scanned, an alert displays to the preparer, and compounding errors are corrected well in advance of the pharmacist verifying the dose. Additionally, with the ability to restrict the route of administration that a product can be used for, we can ensure that the appropriate products are used to compound doses for high-risk routes of administration. For example, only preservative-free products may be used to prepare a dose for intrathecal administration.
The robust beyond-use dating features of the IV workflow system were put to the test at our pediatric facility, where the process of preparing stock IV syringes includes freezing to maximize beyond-use dating and thawing once ready to use. We were able to build frozen and refrigerated versions of stock syringes into the system to enable this process and maintain visibility of the history of the stock syringe from initial preparation down to preparation of the patient-specific dose. This ensures that the pharmacist verifying the patient-specific dose has visibility of all the ingredients, preparation steps, and beyond-use date changes of the stock syringe from initial preparation.
Finally, the IV workflow system routes doses to the appropriate workstation to be prepared based on whether the drug is hazardous, non-hazardous, or oral. This ensures that a hazardous drug is not prepared in a non-hazardous cleanroom, or that an IV dose is not prepared at an oral dose/non-sterile workstation.
Standardization and Beyond-Use Dating
As the EHR system and IV workflow system were shared among all facilities, we were able to standardize dose preparation and beyond-use dating across the region. Prior to implementation of the IV workflow system, recipes for non-patient specific batch doses were maintained separately per facility. These recipes did not align in many cases—for example, in some situations adjustment of the diluent volume was required, but not in other cases. The push to maintain a central, region-wide recipe database ensured standard dose preparation for all facilities. The IV workflow system also allowed customizing and automating the dating based on storage method, diluent, final concentration, and IV hood. This greatly improved our efficiency, as the staff no longer needs to reference disparate IV compounding guides. The flexibility of adjusting beyond-use dating per IV hood also allows for seamless transitions if a compounding location fails an inspection, necessitating quick beyond-use dating adjustments.
As mentioned earlier, the pharmacy informatics team collaborated with pediatric pharmacy leaders to determine the best methods to standardize preparation of doses for pediatric patients. The results of this collaboration allowed for easier preparation of pediatric doses at our adult facilities with built-in calculations in the IV workflow system to reduce errors.
Preparing doses using an IV workflow system inherently introduces additional steps into the process that may initially slow down the pharmacy staff. For example, bar code scanning, image capture, and entering lot/expiration information are all steps that were not part of workflow prior to implementation. We were able to overcome our team’s fear that end user staff would be hesitant to embrace the new system if they experienced a slowdown in dose preparation time by utilizing some additional automation to increase efficiency. One of the features already discussed was automating the beyond-use dating, which reduced the time needed to reference a compounding guide. Another key feature was automation of auxiliary labels, which further reduced the need to reference a compounding guide. These improvements, along with increased visibility into the dose preparation process, allowed for labor- and time-neutral preparation of doses.
Remote Dose Verification
A welcome benefit that presented itself in the current COVID-19 crisis was the ability to utilize the IV workflow system’s robust remote dose verification feature. As health care leaders around the world attempt to reduce the risk of COVID-19 exposure to their frontline staff, methods to enable remote work are being explored.6,7 Many IV workflow systems allow for varying degrees of remote verification, and implementing a product that enables this process at a high level became a powerful asset for us during the current crisis. Pharmacists were able to verify doses without the need to physically inspect the ingredients or final dose in hand. In fact, our pediatric facility was able to successfully transition a portion of its pharmacist staff to work completely remotely in order to minimize potential exposure.
Implementing an IV workflow system increases patient safety and workflow standardization. Robust planning and preparation are key to ensure that a large, multi-hospital health system with diverse service lines can go live successfully. Determining the main project goals at the onset and during system selection is key. Some key issues that should be addressed early on include establishing which types of doses will be prepared via the system, determining what EHR changes will need to occur, selecting the level of standardization your health system would like to achieve, and then developing a plan for training and go-live support.
Hiren M. Shah, PharmD, BCPS, is a pharmacy informatics specialist in the Orlando region of AdventHealth. He completed pharmacy school at the University of Florida College of Pharmacy and went on to pursue PGY1 pharmacy residency training at Lakeland Regional Health in Lakeland, Florida, and a PGY2 pharmacy informatics residency at AdventHealth Orlando.
Craig MacDonald, PharmD, is the Orlando region team lead for pharmacy informatics at AdventHealth. He received his pharmacy degree from Nova Southeastern University and completed a PGY1 pharmacy practice residency at Mercy Health Partners in Muskegon, Michigan, as well as a PGY2 in informatics at the University of Louisville Hospital in Louisville, Kentucky. Craig is responsible for overseeing all the central Florida south region’s pharmacy automation, pharmacy EHR maintenance and improvements, and new solution implementations.