IV workflow management systems (IVWMS) have been identified by ISMP since 2013 as the preferred way for verifying compounded medication preparation.1 These systems help safely streamline several processes. Bar code scanning, consistent medication preparation, volumetric and/or gravimetric preparation verification, beyond use date standardization, and remote verification are some benefits of IV workflow implementation.2 Given these benefits, St. Jude Children’s Research Hospital (SJCRH) made the case for implementing IV workflow based on the need for increased safety checks for high-risk, chemotherapy preparations.

IV workflow management software was first implemented for all chemotherapy preparations in the inpatient areas and the outpatient infusion center in 2010. In 2016, SJCRH implemented a separate IVWMS in non-hazardous IV compounding areas for preparation of stock bags and medication tracking. This same technology was also used for nonsterile compounding verification documentation. It was eventually expanded for verification of non-hazardous patient specific compounding in 2021. The decision to use two disparate systems was driven initially by the tracking system implementation, but then later retained as an interim measure while our hospital began the process of an electronic health record conversion that would lead to conversion to another IVWMS. Despite using two systems, SJCRH created universal policies and procedures for IVWMS identification and implementation that can be used across a multitude of IVWMS.

Evaluating System Options

IVWMS on the market provide a variety of options for compounded product verification. When determining which IVWMS will best fit your organization, the following elements should be central to your evaluation3, 4:

• Requirements of independent medication verification systems (bar code scanning of products, volumetric review, gravimetric assay, etc) for patient specific preparations as well as stock solutions
• Hardware requirements, vendor support, ergonomics, and reliability
• IVWMS integration with existing electronic medical record system
• Cost analysis for software and hardware for initial implementation and ongoing maintenance
• Ability of the IVWMS to fulfill Master Formulation Record (MFR) and Compounding Record (CR) requirements
• Safety features for identifying wrong drug or wrong concentration, dose rejection and error correction communication, high alert or hazardous drug compounding, and additional pharmacist or system checks at steps within or at the end of preparation
• Access to IVWMS data and reporting capabilities

Once a system is identified, it may be necessary to justify the cost of the technology, in which case a multidisciplinary approach is recommended. At SJCRH, the operations team worked closely with the medication safety team, patient care, and the quality department to overcome any barriers related to cost of implementation.

Education and Training

After choosing an IVWMS, it is essential to create standard operating procedures (SOPs) prior to implementation to guide workflow and delineate expectations (see TABLE 1). Most likely, these SOPs will require updating post-implementation; however, having a uniform process for all staff to use as a reference at the time of go live is essential.

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SJCRH previously created a list of expected photographs and documentation with the implementation of our initial IVWMS. When expanding to non-hazardous patient specific medications, we utilized those existing expectations. This standardization helped to ease the transition to a new system and streamlined verification procedures.

When planning education and training for our most recent implementation of IVWMS for nonhazardous patient specific medications, we reviewed and shared existing literature on implementation to ensure that we were addressing key points in system workflow build and in education/training.1-6 In the weeks leading up to implementation, our team utilized training videos and live demonstrations to familiarize staff with the process. During the first week of go live, we had key staff placed with the pharmacists and with the technicians to help provide just in time training on the process and to help manage any issues. TABLE 2 describes the change management steps that were used during implementation.

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Impact of Workflow

Having utilized IV workflow for chemotherapy for 11 years, our staff had already incorporated remote product checking into their process. However, as we expanded the scope of IVWMS, we had to address the following workflow impacts:

• Increased time for preparation—On average, we found that it took about 3 minutes longer to prepare our nonhazardous, patient specific medications through IVWMS compared to the syringe pull-back method.
• Communication expectations for rejected doses, doses that could be corrected, and doses that needed to be completely prepared again—We set the expectation for our team to use our chat program or to directly communicate with the technician. Simply clicking “reject” was insufficient notification as we wanted more immediate feedback and follow-up.
• Printing expectations—Unexpectedly, printing processes and responsibilities required significant discussion. Ultimately, we established that the post-verification label was to be printed by the pharmacist at time of verification, but then applied by the technician. The pharmacist performed a check that the patient label and post verification label matched prior to leaving the pharmacy. We worked with our vendor to limit the number of clicks required to print the label and to address printer selection for the times when a pharmacist needed a printer option beyond the default.
• Setting up the space for safety—In our meetings with frontline staff and the medication safety team, we defined when products would need single final checks (most products), mid-prep checks (high cost, chemotherapy), or double final checks (most high alert products). We also established a designated location for products awaiting verification. The goal was to clearly define which products were ready to be dispensed. This workflow was particularly helpful for our patient specific cart fill (“batch”) compounding given the quantity of products that required preparation and verification within a relatively short time.

Cleaning and Environmental Monitoring

As part of the process for creating and updating SOPs, we outlined the cleaning requirements for the IVWMS equipment. Based on the manufacturer’s recommendations, the iPads could only be cleaned using sterile isopropyl alcohol, but more stringent cleaners could be used for some of the other equipment. We used smoke studies to assign compounding and IVWMS documentation zones within the primary engineering controls. Additionally, as part of our USP <800> compliance plan, we conduct hazardous drug surface sampling (eg, wipe sampling) every 6 months on our IVWMS equipment.

Leveraging IVWMS Data

The data from both types of IVWMS feeds into a dashboard. Since we have disparate systems, the preparation and verification volumes feed into this one dashboard to showcase collated data, but it also allows for data to be filtered by system and by compounding area. We use this data to review staffing alignment with workload, evaluate if workload can be safely completed by pharmacy technicians based on prep time per product per hour, and to report to our executive leadership committee on preparations, medication costs, and waste.

Looking Ahead

Our hospital is in the process of transitioning to a new electronic medical record which will lead to a third IVWMS implementation. We will execute the eight phases described above for workflow planning. The conversion also spurred our teams to complete additional evaluations of hardware and product design.

• Hardware evaluation: In advance of this next conversion, our pharmacy informatics team did a thorough evaluation of camera and equipment options. As a result of having two IVWMS, the pharmacy technicians utilized two distinct equipment setups for compounding medications. Currently, iPads are used for preparation of non-hazardous medications, and a fixed workstation-on-wheels (WOW) setup was used for hazardous medications. The transition to a single IVWMS will allow the operations team to standardize the equipment to a setup like the WOW, wherein a camera is located within the hood with the workstation just outside of it. The existing hardware could not be reused for the new system due to lack of capability. We evaluated several options for our image capturing device based on set-up/configuration difficulty, camera footprint, durability, reliability, and picture quality. Of the evaluated cameras, the operations team and the IT team chose a camera that provided consistent high-quality pictures and is widely utilized by other institutions with IVWMS.
• Hardware set up: Understanding the physical limitations of our small compounding areas, we are currently in the design phase focusing on how each compounder’s workstation will be set up (eg, mounted computer vs WOW). Ergonomics for staff using the system in a small space are also under consideration. We have been working with our facilities and construction team to install more electrical plugs and data ports in the cleanrooms to support the new systems.
• Master formulation record and compounding record compliance: Stock bag and patient specific compounding instructions were extracted from the two current IVWMS. Since each system offered different functionality, the resultant compounding information differed. The operations team is working with the IT team to identify discrete data fields available in the new IVWMS and determined what information could be incorporated into the system fields and what information needed to be presented in the compounding instructions.
• Workflow changes requiring new drug build: Rebuilding medication records for the new system allowed our teams to redesign how some medications are dispensed. For example, PCAs in CADD cassettes historically were prepared for each patient upon request. This new system presented an opportunity to batch compound PCAs in effort to improve operational efficiency and reduce turnaround time. Medication records were built in to support this new process.

Conclusion

As there are several IVWMS available, it is important to carefully review each system to determine the best fit for your facility’s needs. In some cases, more than one system may be appropriate. Developing a strong set of SOPs and training procedures prior to implementation is the key to a successful implementation regardless of the technology chosen.

References

1. Institute of Safe Medication Preparation (ISMP). Maximize benefits of IV Workflow Management Systems by Addressing Work Arounds. Sept. 2017. Accessed February 2022. https://www.ismp.org/resources/maximize-benefits-iv-workflow-management-systems-addressing-workarounds-and-errors
2. Lin AC, Deng Y, Thaibah H, et al. The impact of using an intravenous workflow management system (IVWMS) on cost and patient safety. Int J of Medical Informatics. 2018;115:73-79.
3. McCoy AR. An IV workflow management system implementation journey. Pharm Purch Prod. June 2019;16(6)12-16.
4. KLAS Research. IV Workflow Management. Accessed on March 5, 2022. https://klasresearch.com/compare/iv-workflow-management/196
5. Meyers C, King E, Barnes NE. Maximize Use of IV workflow management software. Pharm Purch Prod. 2020;17(5):2-6
6. Shah HM, McDonald C. Implementing and IV workflow management system. Pharm Purch Prod. Sept 2020;17(9):8.

Cindy Brasher, PharmD, MS, BCPS, BCSCP, is the manager of compounding at St. Jude Children’s Research Hospital (SJCRH). She received her PharmD from the University of Tennessee College of Pharmacy, completed the health systems pharmacy administration PGY1/PGY2 residency program at Mission Hospital in Asheville, North Carolina, and a master’s in pharmacy administration through the University of North Carolina Chapel Hill. Currently, Cindy is serving on the ASHP Section Advisory Group on Compounding, ACCP Clinical Administration PRN, and the UT Alumni Association Board of Governors.

Kevin Smith, PharmD, HMBA, BCPS, is an EHR application analyst for Epic’s Willow Inpatient at SJCRH. He earned his PharmD from the University of Tennessee College of Pharmacy, completed a PGY1 at The Regional Medical Center at Memphis, and earned his Master of Business Administration in Healthcare Management from Christian Brothers University.

Calvin C. Daniels, PharmD, PhD, BCPPS, DPLA, is an EHR application analyst at SJCRH. He received his PhD in microbiology at the University of Alabama at Birmingham and his PharmD from the University of Tennessee College of Pharmacy. He completed a PGY1 Pharmacy Practice residency at Children’s of Alabama and a PGY2 Medication-Use Safety Residency at SJCRH.