St. Joseph’s/Candler Hospital in Savannah, Georgia is a not-for-profit health care institution that evolved from the merger of two hospitals to create one health-care system. St. Joseph’s is a 305-bed hospital and Candler has about 331 beds. Specialized care is offered in centers of excellence including The Heart Hospital, the Nancy N. and J. C. Lewis Cancer and Research Pavilion, the Mary Telfair Women’s Hospital, the Institute for Advanced Bone and Joint Surgery, and the Institute of Neurosciences.
Past and Future
For many of us who started in medicine some years back, we remember medication rooms where licensed practical nurses (LPNs) dispensed medication from large bottles of pills or liquid. These agents were stored in drawers for each patient. There was no need to accommodate computerized carts, computers on wheels (COWs), or automated dispensing cabinets. Now medications are unit based and supplied in single doses, and many hospitals use automated dispensing cabinets for medication dispensing and storage.
For the Institute of Neurosciences, on the second floor at St. Joseph’s, we wanted a state-of-the-art unit and medication room. We worked closely with our architect to achieve this goal. We visited hospitals in several states, including Georgia, Florida, South Carolina, Indiana, and Ohio, to study and evaluate their systems. On these trips, I was accompanied by my charge and staff nurses from both the day and night shifts. Seven of us visited eight different hospitals. We considered the square footage at our disposal at St. Joseph’s, our goals for the patient rooms, what was needed at our nurses’ station and physicians’ area, and what the ideal medication room would look like.
Studying the layouts and designs of other facilities made planning our facility easier. We compiled a list of the features we admired in other facilities, including considerations such as room size and work space that was sufficient enough to allow complete accessibility for staff with carts. Appropriate security, quality lighting, and controlled noise level were also key features for us. Furthermore, we wanted our cabinetry, sink, sharps container, and pneumatic tube system to be conveniently located. From this list and with our architect’s guidance, we developed an architectural plan that was posted on bulletin boards in our nurses’ station. We encouraged the input of pharmacists, nurses, and medical personnel, noting that it might not be possible to address all their concerns, but anything architecturally feasible would be considered. It is very important to have staff input in the planning stage so that everyone can have a part in the design process.
In the past, medication rooms were part of the nurses’ station, but today, these rooms must be centralized and easily accessible to all staff. This is especially true on an intensive care unit where medical emergencies might demand the use of certain agents in a matter of seconds. Nurses cannot be running down the hall for the computerized cart in a life-threatening situation. The medication room must be centrally located to all rooms on the unit.
Our Neurosciences Unit is about 13,000 square feet and includes glass walls in the front, right, and left of the unit with our central supply area located at the rear of the unit. With this layout, the entire area is completely visible to a clinician standing in the middle of the unit. The centrally located medication room layout is ideal in many respects: it is almost totally glass enclosed, it is highly visible to all on the unit, and it is secure. Furthermore, it is relatively soundproof, which allows staff to concentrate when pulling medications, yet remain visible from both inside and outside the room. We considered including a small window between the physicians’ area and the medication room so physicians and nurses could communicate directly with each other, but ultimately, we decided against this due to the importance of total concentration on the part of the nurse during medication preparation.
We designed the room to be secure. The doors are secured with a key-punch access system, which we opted for over a badge-swipe system out of budget concerns. Key-punch access limits entrance to the room to nurses, pharmacists, and respiratory therapists only. Physicians do not have access to the medication room because it is strictly a pharmacy/nursing control area. Environmental Services personnel must request access to empty the trash receptacles, and the limited foot traffic helps keep the room clean. Controlled substances are secured in the Pyxis system. Our two adult crash carts are not in the medication room, but are strategically located at either end of the unit, and the pediatric cart is stored outside the medication room.
Within the medication room there are four sections of drawers below the countertop for storing non-drug items such as filters, alcohol swabs, tape, adhesive bandages, and syringes. My directive to the nurses, pharmacists, and respiratory therapists was to arrange these non-drug items in the most logical manner according to frequency of use. It is crucial that those who use these supplies the most manage the process of arranging them in the most accessible manner. The only instruction was to keep the countertop clean and free of clutter with the exception of a telephone or computer. Staff input is important to ensure any unit, as well as its medication room, functions successfully.
We accomplished all of this — from design to construction and implementation of the new unit and medication room — in approximately two years. Because of our upfront preparation, the construction crew, when they arrived in June 2007, hit the ground running, and it took them approximately 10 months to complete the unit. Our experience showed that a single person should be appointed to act as the liaison with the architect and builder during construction in order to expedite results and maintain good working relationships. We started with a concept in 2006, and the unit and medication room were completed and work-ready in April 2008.
Logistics of the Medication Room
We have twelve patient rooms in the unit, with a ratio of one nurse to every two patients, so there are six nurses on the unit at any given time. Each nurse is assigned a COW, which is stored at a nursing pod (a small alcove with a desk) located between every two rooms. The medication room is spacious enough so that two or three nurses can be there together with their COWs and still work efficiently. We chose not to put mats on the floor in the medication room so the COWs could easily roll in and out.
The countertop and floor tiles are a dark green color. This way, if a medication is dropped or crushed on the floor, the color contrast makes it more visible than it would be against a beige or white surface.
Mounted on the wall are sharps containers, a bulletin board, and an eye wash kit next to the sink in the event of a harmful splash. An intercom system located in the room can call nurses when they are needed on the unit or wanted on the phone by physicians or other hospital personnel. Extra lighting per square foot was installed to ensure accuracy for medication preparation. After reviewing the types and amounts of medications requiring refrigeration, we chose a small under-the-counter refrigerator with temperature-monitoring features to meet required regulations.
At the nursing/staff desk in the unit itself, we have six computer stations shared by pharmacy, respiratory therapy, and speech, occupational, and dietary services. The nurses (and their COWs) sit in tandem at their pods between the patients’ rooms with high patient visibility due to the glass windows. There is a computer on the counter in the medication room, however, it is only used occasionally as the nurses are more likely to use their wireless COWs. The pneumatic tube system for stat or new medications is located next to the medication room, making it convenient for us to request additional medications as needed from the pharmacy, which pharmacy then sends immediately.
Efficient medication rooms can effectively improve the quality, as well as the cost-effectiveness, of care. Our new medication room provides improved work flow processes which result in higher staff satisfaction, fewer medication errors, decreased wait time for medication preparation and administration, and better utilization of supplies with less waste. The success of this project was dependent on the homework we did prior to the implementation. The more you observe and plan in advance, the better your outcome will be. We worked closely with our architect, our builder, and relied on our entire staff for input and advice. As a result, all of the staff is pleased with the streamlined workflow and proud of the end result.
Diane Hinely, MSN, RN, is the manager of neuroscience, at St. Joseph’s/Candler Hospital in Savannah, Georgia. She has worked at the hospital in different capacities for the past 26 years.
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