Inpatient pharmacies regularly utilize a batching system to allow advance preparation and timely delivery of scheduled doses. By varying the number of batches and label print times to group similar types of dispenses, pharmacy can reduce waste and optimize staff productivity. However, the use of batching has several limitations: orders may be discontinued after a dose is prepared, workload may be distributed unevenly, and doses may be prepared at suboptimal times.
To address these limitations, IV workflow vendors and electronic health record (EHR) platforms have incorporated dispense queue systems that collate and continually update medication orders. These systems allow pharmacy staff to triage which orders to print and process at which time; thus, offering the potential to increase efficiency and address the limitations of traditional batching systems.
BUD Concerns Drive Adoption
The University of Iowa Stead Family Children’s Hospital (SFCH) is an academic medical center that includes 253 inpatient beds for pediatrics and adult labor and delivery. In the spring of 2020, looming personal protective equipment (PPE) shortages due to the COVID-19 pandemic required planning for worst-case scenarios, including shifting to shortened beyond use dating (BUD) for sterile compounds.
To address workflows with shortened BUDs, the pharmacy adopted a queue system that integrates within the EHR to collate all medication orders. This system would centralize orders to prioritize compounding while simultaneously eliminating the need to keep printed labels manually organized. Fortunately, the shift to shortened BUDs was not implemented as SFCH’s PPE supply remained healthy.
Nevertheless, the queue system has persisted as part of routine workflows, even as its utility has evolved. Today, the queue manages most sterile and nonsterile medication first dose orders and select batches. The queue is managed at one workstation by one technician (stager) in a central area of the pharmacy. By describing SFCH’s usage of the queue system, we aim to provide guidance for future adopters.
Establishing a Queue System
When setting up a queue system for an inpatient pharmacy, first define the intended outcomes of the system to best guide logistical design. By deciding upon these outcomes in advance, usage will align across teams and guide future decisions when new scenarios for using the queue are considered. For our operation, key queue system goals were:
The following considerations were discussed by the SFCH team when implementing a dispense queue. However, it is important to note that this list may need to be modified to reflect the specific queue set up at your facility, such as having multiple workstations with each managing different product types (ie, sterile vs. nonsterile and hazardous vs. nonhazardous).
Medications Assigned to the Queue
A queue can be used to manage all or select medication orders for the pharmacy. Having all orders flow through the queue system may be beneficial in achieving set goals, but this can also create new stressors. Having a high order volume can be daunting to staff managing the queue. Staff may end up feeling the need to clear the queue or to print out a large volume of labels to combat this feeling of endless work. However, this contradicts the intended purpose of the technology. There must be a balance between orders managed through the system and orders set to bypass the queue and print automatically.
Consider the following variables related to dispense type when deciding if an order should enter the queue. The degree of filtering or customization can vary among queue systems.
Staff Expectations for the Queue
The queue’s effectiveness is ultimately dictated by the front-line personnel. Defining expectations and exceptions for select scenarios are essential for cohesive and consistent queue management.
While technical considerations among queue systems can vary, a few universal concepts are applicable. First, it is important to understand the compatibility of your institution’s supported hardware, what the queue system requires, and the pharmacy’s operational needs. For example, touchscreens are ideal for tight spaces, and potentially in cleanrooms, to limit excess hardware. Next, consider the queue’s refresh rate or how often the system looks for order updates. In SFCH, the default, hard-coded refresh rate is 5 minutes, but users can update manually as needed. Similarly, make sure to address the system’s time-out setting for inactivity to balance functionality and security. For SFCH, the time-out setting is 20 minutes, allowing technicians to move away from the queue workstation for other tasks. Reducing the frequency of logging in saves time and minimizes frustrations.
Since adopting a medication dispense queue, SFCH technicians have expressed feeling less overwhelmed due to their increased ability to control the pace of work. Successfully integrating a queue system into an operational model requires both a methodical selection of what orders flow into the system and explicit definitions for how orders flow out. Dispense queues are a dynamic tool that can increase organization and flexibility within a pharmacy.
Felix Lam, PharmD, MBA, BCPS, is the pediatric pharmacy operations manager for University of Iowa Hospitals & Clinics in Iowa City, Iowa. He earned his doctor of pharmacy from the University of North Carolina Eshelman School of Pharmacy and his MBA with an emphasis on health care management from the Johns Hopkins Carey Business School while completing a combined PGY1/PGY2 in health-system pharmacy administration at The Johns Hopkins Hospital.
Curt Balk, CPhT, is a senior informatics specialist at the University of Iowa Hospitals & Clinics in Iowa City, Iowa. He attended the University of Iowa majoring in Microbiology and began working as a certified pharmacy technician at the University of Iowa Hospitals & Clinics in 2000.
Camryn Froerer, PharmD, MS, BCPS is an adult pharmacy operations manager for University of Iowa Hospitals & Clinics in Iowa City, Iowa. He earned his doctor of pharmacy degree from the University of Utah College of Pharmacy. Camryn attained his MS in pharmacy administration at the University of Utah while completing a combined PGY1/PGY2 in Health-System Pharmacy Administration at the University of Utah Health.