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UBC Theses and Dissertations

Developing hospital pharmacy services based on unit dose drug distribution Hill, David Stewart 1973

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DEVELOPING HOSPITAL PHARMACY SERVICES BASED ON UNIT DOSE DRUG DISTRIBUTION by DAVID STEWART HILL B.Sc.(Pharm.), University of B r i t i s h Columbia, 19 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n the D i v i s i o n of C l i n i c a l Pharmacy of the Faculty of Pharmaceutical Sciences We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July, 1973 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by h i s representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of C l i n i c a l Pharmacy i n the Faculty of Pharmaceutical Sciences. The University of B r i t i s h Columbia Vancouver 8, Canada Date July 20, 1973. ABSTRACT There are many examples i n the l i t e r a t u r e of conventional or t r a d i t i o n a l drug d i s t r i b u t i o n systems i n h o s p i t a l s which possess many shortcomings with reference to medication e r r o r s , the amount of time spent by nursing personnel i n medication-related duties, inventory losses, the preparation of intravenous admixtures, and the lack of adequate drug usage records. These d e f i c i e n c i e s p r i m a r i l y are due to the pharmacist's minimal influence over the control of the t r a d i t i o n a l drug d i s t r i b u t i o n systems. An analysis and evaluation of the present pharmacy services at St. Paul's H o s p i t a l , Vancouver, B.C., s i m i l a r l y i d e n t i f i e d aetcadjLtional d i s t r i b u t i o n system subject to many of the aforementioned p o t e n t i a l problems. Using information based on e x i s t i n g unit dose systems as reviewed i n the l i t e r a t u r e and data c o l l e c t e d from a general questionnaire, new pharmacy services based on unit dose drug d i s t r i b u t i o n are projected f o r St. Paul's H o s p i t a l . The required f a c i l i t i e s and personnel f o r a progressive unit dose drug d i s t r i b u t i o n system, an intravenous (I.V.) admixture preparation service and a drug s u r v e i l l a n c e program are projected accordingly. It would appear that a " c e n t r a l i z e d " approach to implementing unit dose d i s t r i b u t i o n i s most appropriate for St. Paul's Hospital's present requirements. This would involve the preparation and d i s t r i b u t i o n of a l l drugs to nursing units i n si n g l e dose packages from a c e n t r a l pharmacy area. A s i m i l a r l y c e n t r a l i z e d intravenous admixture service and a decentralized drug s u r v e i l l a n c e program also are described. These services commonly feature a greater r e s p o n s i b i l i t y being placed with the pharmacy department f o r i i preventing therapy problems such as admixture incompatibilities, drug interactions, adverse drug reactions and inappropriate drug selection. The effect of the above services on the responsibilities and number of pharmacy and nursing personnel i s estimated based on results in similar programs. These changes also reflect extended hours of coverage in each area. Finally, a potential phasing plan and time schedule for the implementation of the proposed unit dose drug distribution system, I.V. admixture preparation service and drug surveillance program at St. Paul's Hospital is suggested. Signature of Superyisor. i i i ACKNOWLEDGEMENTS The author wishes to express his gratitude to Dr. J.N. Hlynka f o r h i s i n i t i a l suggestion concerning the graduate studies program and hi s encouragement and guidance throughout the course of t h i s study. Appreciation i s also extended to Mr. J.G. Moir and Miss E. Yakimets f o r t h e i r assistance i n providing some of the l i t e r a t u r e material and unpublished reports used i n t h i s work. The cooperation received from Mr. W. Ince at St. Paul's H o s p i t a l was extremely h e l p f u l . A s p e c i a l thanks i s extended to Mr. D. DuPlessis and Mr. J . Dancey f or t h e i r comments and c r i t i c i s m s of the r e s u l t s of t h i s project. The f i n a n c i a l assistance from the Geigy Pharmacy Scholarship and the Univ e r s i t y Graduate Fellowship i s g r a t e f u l l y acknowledged. DEDICATED TO Sandra i v TABLE OF CONTENTS Page ABSTRACT i ACKNOWLEDGEMENTS i i i TABLE OF CONTENTS i v LIST OF TABLES . v i i LIST OF FIGURES i x LIST OF APPENDICES . . . . x INTRODUCTION 1 LITERATURE SURVEY 5 A. Modified T r a d i t i o n a l Drug D i s t r i b u t i o n Systems . 5 B. Unit Dose D i s t r i b u t i o n 7 Centralized Unit Dose D i s t r i b u t i o n . . 9 Decentralized Unit Dose D i s t r i b u t i o n . . 10 Other Contemporary Features i n Drug D i s t r i b u t i o n . . . . . . . . . . 13 The Consequences of Unit Dose D i s t r i b u t i o n . 16 Unit Dose D i s t r i b u t i o n i n Canada . . . 21 C. Intravenous Admixture Preparation . . . . 23 D. Drug Surveillance 27 E. A S p e c i f i c S i t u a t i o n 30 STATEMENT OF PROBLEM 33 EXPERIMENTAL METHODS 34 A. General 34 B. St. Paul's Ho s p i t a l 34 V TABLE OF CONTENTS (Continued) Page C. General Information Survey 35 D. L i t e r a t u r e Approaches 36 RESULTS AND DISCUSSION 39 A. St. Paul's H o s p i t a l Analysis 39 Ho s p i t a l 39 Pharmacy Department 39 Pharmacy Drug D i s t r i b u t i o n 43 I.V. Therapy Service 49 Drug Information and Education . . . . 52 B. L i t e r a t u r e Evaluation 53 C. General Information Survey 55 D. Drug D i s t r i b u t i o n 56 Unit Dose Systems Analysis 56 Proposed Unit Dose D i s t r i b u t i o n System . 64 E. Intravenous (I.V.) Admixture Service . . . . 85 Intravenous Admixture Systems Analysis . 85 Proposed I.V. Admixture Service . . . 89 F. Drug Surveillance Program 102 Drug Surveillance Systems Analysis . . . 102 Proposed-Erug Surveillance Program . . . 104 G. Phasing 110 Drug D i s t r i b u t i o n I l l Intravenous Admixture Preparation . . . 112 v i TABLE OF CONTENTS (Continued) Page Drug Surveillance Program 113 Suggested Schedule 114 SUMMARY 116 BIBLIOGRAPHY 121 APPENDICES 129 v i i LIST OF TABLES Table Page I COST OF DRUG ALLOCATIONS FROM PHARMACY TO NURSING UNITS AT ST. PAUL'S HOSPITAL . . . 41 II REPRESENTATIVE DAILY PHARMACY DEPARTMENT WORKLOAD AT ST. PAUL'S HOSPITAL . . . . 48 III HOSPITAL STATISTICS, SERVICES, AND PHARMACY WORKLOAD OF SEVERAL CENTRALIZED AND "COMBINATION" UNIT DOSE HOSPITALS . . . . 57 IV HOSPITAL STATISTICSi SERVICES, AND PHARMACY WORKLOAD OF TWO DECENTRALIZED UNIT DOSE HOSPITALS % . 58 V STAFFING, HOURS OF SERVICE AND AUXILIARY PROGRAMS FOR SEVERAL CENTRALIZED AND "COMBINATION" UNIT DOSE HOSPITALS . . . . 62 VI SUMMARY OF PRESENT AND PROPOSED MEDICATION DISTRIBUTION SYSTEMS AT ST. PAUL'S HOSPITAL . 65 VII PROPOSED CART IDENTIFICATION PLAN AND UNIT DOSE PREPARATION RESPONSIBILITY FOR ST. PAUL'S HOSPITAL 77 VIII NURSING TIME SAVING OF VARIOUS HOSPITALS AFTER IMPLEMENTATION OF UNIT DOSE AND EXTRAPOLATION TO 575 BEDS 83 IX SUMMARY OF COMPARATIVE PERSONNEL REQUIREMENTS FOR PHARMACY. DRUG DISTRIBUTION AT ST. PAUL'S HOSPITAL 84 v i i i LIST OF TABLES (Continued) Table Page X WORKLOAD AND STAFF COVERAGE OF FIVE HOSPITALS WITH PHARMACY INTRAVENOUS ADMIXTURE SERVICE 88 XI SUMMARY OF PRESENT AND PROPOSED INTRA-VENOUS ADMIXTURE SYSTEMS AT ST. PAUL'S HOSPITAL 90 /XII NURSING TIME SAVING OF THREE HOSPITALS AFTER IMPLEMENTATION OF AN I.V. ADMIXTURE PREPARATION SERVICE AND EXTENSION TO ST. PAUL'S HOSPITAL'S CHARACTERISTICS . . 100 XIII SUMMARY OF THE COMPARATIVE PERSONNEL REQUIREMENTS FOR THE I.V. ADMIXTURE SERVICE AT ST. PAUL'S HOSPITAL 101 XIV SUMMARY OF PRESENT AND PROPOSED DRUG SURVEILLANCE PROGRAMS AT ST. PAUL'S HOSPITAL . . . . . 105 XV SUMMARY OF PROJECTED COMPARATIVE PERSONNEL REQUIREMENTS AS A RESULT OF PROPOSED PHARMACY SERVICES AT ST. PAUL'S HOSPITAL . . . . 118 ix LIST OF FIGURES Figure Page •1. QUESTIONNAIRE 37 •2. PRESENT DRUG DISTRIBUTION SYSTEM AT ST. PAUL'S HOSPITAL 44 3. PRESENT I.V. THERAPY SYSTEM AT ST. PAUL'S HOSPITAL 51 4. PROPOSED UNIT DOSE DISTRIBUTION SYSTEM AT ST. PAUL'S HOSPITAL 6'9"> 5. UNIT DOSE PREPARATION AND STAFF SCHEDULE FOR DAY SHIFT AT ST. PAUL'S HOSPITAL . . 79 ; 6 . UNIT DOSE PREPARATION AND STAFF SCHEDULE FOR AFTERNOON SHIFT AT ST. PAUL'S HOSPITAL . 80 7. PROPOSED I.V. THERAPY ADMIXTURE SERVICE AT ST. PAUL'S HOSPITAL 9 # 8. POTENTIAL PHASING SCHEDULE FOR THE PROPOSED PHARMACY SERVICES AT ST. PAUL'S HOSPITAL : LIS-X LIST OF APPENDICES Appendix Page I PHYSICIAN'S OEDER FORM (ST. PAUL'S HOSPITAL) 129; II MEDICATION RECORD (UNIVERSITY OF KENTUCKY MEDICAL CENTER) \ 3 0, II I MEDICATION MEMORANDUM (ST. PAUL'S HOSPITAL) 131 IV (a) SCHEDULED MEDICATIONS RECORD . . . 132 (b) NON-SCHEDULED MEDICATIONS RECORD . . 133 (UNIVERSITY OF WISCONSIN HOSPITALS) V DRUGS NOT GIVEN NOTICE (UNIVERSITY OF KENTUCKY MEDICAL CENTER) . . . . . . . 134 VI NOTICE OF AUTOMATIC STOP ORDER (UNIVERSITY OF KENTUCKY MEDICAL CENTER) 135 VII PHARMACY NARCOTIC DISPOSITION RECORD AND 24 HOUR NURSING AUDIT RECORD (THE JOHNS HOPKINS HOSPITAL) 136 VIII I.V. ORDER CARD (THE MOSES H. CONE MEMORIAL HOSPITAL) 137 IX PHARMACEUTICAL SERVICE RECORD (MEMORIAL HOSPITAL OF LONG BEACH) 138 X PHARMACY SHEET (ST. PAUL'S HOSPITAL) . . . 139 INTRODUCTION The evolution i n h o s p i t a l pharmacy p r a c t i c e within the past decade has' been from a primary emphasis on drug d i s t r i b u t i o n to a greater r e s p o n s i b i l i t y i n the patient-care or c l i n i c a l environment. This r e d i r e c t i o n of involvement i s the fundamental theme of the majority of h o s p i t a l or " c l i n i c a l " pharmacy l i t e r a t u r e . Kleinmann(l) however, states that ". . . a h o s p i t a l must f i r s t develop concepts of good pharmaceutical services before i t should even consider moving i n a progressive d i r e c t i o n . " Therefore, e f f i c i e n t medication d i s t r i b u t i o n systems are prerequisites to e f f e c t i v e p a r t i c i p a t i o n by pharmacy personnel i n the patient-care environment. The h o s p i t a l pharmacist's role i n the t r a d i t i o n a l or conventional drug d i s t r i b u t i o n system i s l i m i t e d . In t h i s system the h o s p i t a l pharmacy department d i s t r i b u t e s medication by i n d i v i d u a l p r e s c r i p t i o n s or as ward or f l o o r stock. In e i t h e r case issues are by multiple u n i t s . A f t e r the medications have been d i s t r i b u t e d the pharmacy has l i t t l e c ontrol over t h e i r usage. Barker(2) states that he does " . . . not believe the h o s p i t a l pharmacist has a future i n the d i s t r i b u t i o n of drugs i n h o s p i t a l s . " This i s i n reference to drug d i s t r i b u t i o n as the p h y s i c a l act of counting, repackaging and trans-porting of drugs. His expanded r e s p o n s i b i l i t y , however, w i l l be to provide the c o n t r o l l i n g influence over t h i s system. Drug control involves the exertion of a d i r e c t r e s t r a i n i n g or governing influence over the use of drugs(2) and the process by which the ordered dose i s made ready for 2 administration(2,3). Further, the demand to lessen the involvement by nursing personnel in medication related duties and to reduce the possibility of medication errors are basic reasons for intensifying pharmacy's participation in the patient-care areas. Medication errors have been shown to occur with alarming frequency. In conventional drug distribution systems, these errors are generally considered to occur at a rate of 15 to 18 percent of doses ordered(4). A study by Hynniman and coworkers(4) comparing the frequency of medication errors in four hospitals demonstrated that a rate of 8.3 percent to 20.6 percent could be expected with distribution systems u t i l i z i n g the prescription order and floor stock concept. Barker and Heller(5) reported a preliminary study before the implemen-tation of an experimental unit dose system showed medication errors occurred at a rate of 8 to 15 percent when wrong time errors were not included. It is quite apparent that with conventional hospital'drug distribution methods, approximately one out of every six or seven doses ordered is handled in a manner contrary to physician's instructions(6,7). It is important to realize that errors in the traditional systems are caused by physicians, nurses and pharmacists and that the interpretation of "medication errors" must not mean solely nursing errors. It is also recognized that the stat i s t i c s reported for medication errors are dependent on different patterns of dosage form u t i l i z a t i o n , drug doses, times of administration, and medication schedules of the individual hospitals(4) and the specific c r i t e r i a used to define a medication 3 error. However, as one h o s p i t a l administrator has stated, "Even i f the vast majority of reported errors are of the less serious v a r i e t y ( i . e . , wrong time of administration, omission, wrong dose or extra dose given)*, the r i s k i s too great to to l e r a t e an at t i t u d e of unconcern"(7). Progressive trends i n h o s p i t a l pharmacy serv i c e s , s p e c i f i c a l l y unit dose d i s t r i b u t i o n and drug s u r v e i l l a n c e programs (reviews of drug usage), are designed to greatly reduce medication e r r o r s . It should be noted that medication errors contributed by nursing personnel cannot be viewed as t o t a l l y unexpected when one considers the p o s i t i o n of the nurse i n the present "drug d i s t r i b u t i o n cycle". In the course of assigned nursing duties, she may be expected to i n t e r p r e t physicians' medication orders, select correct drugs from large f l o o r stock supplies, compound d i f f i c u l t and extremely potent pharmaceuticals such as intravenous admixture preparations, and often assume complete r e s p o n s i b i l i t y over the drug d i s t r i b u t i o n system during night and weekend periods. In f a c t , i n many hospitals? the proportion of time i n which nursing personnel have unsupervised access to the pharmacy department (during evening and night s h i f t s ) i s s u b s t a n t i a l l y greater than the coverage provided by pharmacists during normal day periods (usually eight to ten hours). Several studies have reported that nurses normally spend from 22 to 30 percent of a v a i l a b l e time i n medication r e l a t e d a c t i v i t i e s ( 8 , 9 ) . These duties usually involve the noting of physicians' medication orders, r e q u i s i t i o n i n g drugs from the * Internal brackets added by author. 4 pharmacy, preparing doses f o r administration, transporting drugs, administering of medications and charting. A study on f i v e nursing units i n a large u n i v e r s i t y h o s p i t a l reported that registered nurses spent an alarming 47.3 percent of t h e i r time with medication re l a t e d procedures(10). Again i t i s recognized that these s t a t i s t i c s w i l l vary with i n d i v i d u a l h o s p i t a l procedures, p o l i c y and personnel assign-ments. In a multiple dose ( t r a d i t i o n a l ) system reported by Riley and coworkers(11) at the Johns Hopkins H o s p i t a l , the time spent i n medication duties performed by nursing personnel ranged from 29 percent f o r unit clerks to 30 percent f o r licensed p r a c t i c a l nurses and 40 percent f o r r e g i s t e r e d nurses. Two Issues are c l e a r l y evident here: (1) the large proportion of a v a i l a b l e nursing time spent i n a c t i v i t y which i s not patient-care management of pro f e s s i o n a l nursing nature, and (2) the p o t e n t i a l f o r serious adverse consequences when nursing personnel are required to carry out functions for which they are not educated]toe •' iperf orm:  '.ly q : ; ? l i i i e d r^rf - t r m Individual approaches to drug d i s t r i b u t i o n , intravenous admixture services and drug s u r v e i l l a n c e programs have been proposed to r e a l i z e changes i n the roles of pharmacists, nurses, and physicians related to drug therapy. H o s p i t a l s i z e , type, management, t r a d i t i o n and personal preferences of pharmacy and nursing w i l l determine the extent to which these systems and r e s p o n s i b i l i t i e s are implemented(12). This l i t e r a t u r e survey w i l l review several well-documented examples to describe the res u l t s of t h i s progressing trend. 5 LITERATURE SURVEY A. Modified T r a d i t i o n a l Drug D i s t r i b u t i o n Systems. One of the i n i t i a l attempts to reduce the amount of time delegated to medication a c t i v i t i e s by nurses was the development of the "Medication Order Supply and Ind i v i d u a l Charge System" (MOSAICS). F i r s t described by Tucci and Webb at Massachusetts General Hospital(13), t h i s system requires that the pharmacy assumes the r e s p o n s i b i l i t y f o r the stocking, dispensing, and charging of charge medications on each nursing u n i t . B a s i c a l l y , t h i s i s a well-supervised, perpetual inventory ward stock system. The major function of the pharmacists i n the MOSAICS i s to maintain an active supply of a l l medications currently being administered on t h e i r assigned unit. These decentralized areas are usually composed of three or four nursing units serving from one hundred to two hundred patients. This system has subsequently been described i n Canadian h o s p i t a l s by Greve(14) and Cramp(15) at the Toronto Western Hospital and by Dasko and Greene at the Humber Memorial H o s p i t a l ( l 6 ) . In Canada, t h i s acronym refe r s to "Medication Order Supply and Inventory Control System" since drugs are ra r e l y "charged" to the patient. The advantages of the MOSAICS are: 1. Relieves the nurse of the routine checking of supplies; 2. Reduces the drug inventory on nursing units thereby minimizing storage areas; 3. Delays i n drug administration are avoided since routine drugs are ava i l a b l e i n nursing units 6 twenty-four hours per day; 4. Eliminates the pr a c t i c e of c r e d i t i n g unused medications returned to the pharmacy from nursing un i t s ; 5. Makes a pharmacist a v a i l a b l e i n the patient-care areas to physicians and nurses to receive and answer drug information requests(13). Unfortunately, the d e f i c i e n c i e s of t h i s system are major. The pharmacist i s assigned many duties of a d i s t r i b u t i v e nature which reduce the amount of time he can devote to drug information and sur v e i l l a n c e services. MOSAICS does not lend i t s e l f w e l l to the e f f i c i e n t u t i l i z a t i o n of supportive personnel except i n prepackaging and transportation functions. Therefore, the s t a f f i n g requirements to provide t h i s extended coverage by pharmacists may be p r o h i b i t i v e when compared to the benefits which may accrue from t h i s system. However, thi s method has s p e c i f i e d a control r e s p o n s i b i l i t y f o r pharmacists i n the patient-care areas. Dr. Elmina M. P r i c e , a nurse-researcher, describing her " i d e a l " drug d i s t r i b u t i o n systems s t a t e s : " I f the pharmacist can be better u t i l i z e d as a resource person i n regard to drug therapy while located i n a subpharmacy, this would seem to be compatible with nursings' goals. The MOSAIC system appears to accomplish some improvement i n this d i r e c t i o n " ( 1 7 ) . The concepts of expanded pharmacy con t r o l over drugs and reduced nursing involvement i n medication a c t i v i t i e s introduced by MOSAICS are furth e r refi n e d to reduce these disadvantages i n the rapid development of the unit dose d i s t r i b u t i o n system. 7 B. Unit Dose Distribution. The drug distribution systems described in hospital pharmacy literature within the past decade, almost without exception are based on unit dose packaging. "Unit of use", "single unit packaging" and "unit dose" are terms referred to in unit dose distribution systems. A unit dose may simply be defined as ". . . any physical quantity of a drug specified by a physician to be administered to a patient at one time, and not requiring any significant physical or chemical alterations before being administered"(18). A unit dose drug distribution i s , therefore, 11. . . a total system which delivers a pre-calculated, prepared, pre-labeled dose of medication in a ready to administer form for one patient for one specific time period of administration"(19). The essential features of a unit dose distribution system which differ from the traditional drug distribution method are: 1. A l l physicians' medication orders are received in the pharmacy as a direct copy (via carbon paper,, no-carbon-required paper, or photoduplication) rather than as a transcribed order; 2. A l l medication orders are recorded in the pharmacy (either manually or electronically) rather than solely on drug administration records maintained by nurses; 3. The great majority of drugs are included in the system so that free floor stocks available to nursing units are greatly restricted; 4. Medications distributed to the nursing units in the unit dose system are limited to quantities for several 8 hours rather than several days; 5. Nurses are not responsible f o r any medication preparation since drugs are sent to nursing units from the pharmacy i n a ready to use form; 6. Drug doses are c l e a r l y i d e n t i f i a b l e up to the time of administration because of packaging character-i s t i c s ; 7. Pharmacy receives n o t i f i c a t i o n of the fate of a l l doses d i s t r i b u t e d whether administered or not. One of the most s i g n i f i c a n t q u a l i t i e s of unit dose d i s t r i -bution i s that i t has been shown to be a v i a b l e system i n many diverse s i t u a t i o n s . Successful unit dose systems have been reported i n very small h o s p i t a l s (20,21,22,23) where f i n a n c i a l support and necessary s t a f f i n g may be l i m i t e d . In contrast, unit dose d i s t r i b u t i o n systems have been implemented i n very large h o s p i t a l s and i n s t i t u t i o n s with u n i v e r s i t y a f f i l i a t i o n (24,25,26,27) where f a c i l i t i e s and s t a f f may be a v a i l a b l e but the very magnitude of the services to be provided may be s u b s t a n t i a l . This system has been described i n private and community hospitals(28,29,30). Mental(31) and pediatric(32,33) h o s p i t a l s where services may be more s p e c i a l i z e d when compared to general, acute care i n s t i t u t i o n s , also have reported the use of unit dose d i s t r i b u t i o n . F i n a l l y , the preparation and c o n t r o l of very s p e c i a l i z e d unit dose pharmaceuticals such as i n v e s t i g a t i o n a l parenteral cancer chemothera-peutic agents has been described(34). In each s i t u a t i o n , the h o s p i t a l has implemented a unit dose d i s t r i b u t i o n system to f u l f i l i t s own s p e c i f i c requirements. 9 Centralized Unit Dose D i s t r i b u t i o n . Of the two major unit dose systems, the c e n t r a l i z e d method has received the most documentation. In t h i s system a l l physicians' medication orders are received and interpreted i n a c e n t r a l pharmacy with unit dose medications being prepared and d i s t r i b u t e d from that same l o c a t i o n . In most ce n t r a l i z e d systems, nursing personnel are only responsible f o r noting the physician's orders, administering medications and charting of doses. Nurses are not required to prepare or compound medications p r i o r to administration. Pharmacists or pharmacy supportive personnel i n t e r p r e t physicians' orders and manually or e l e c t r o n i c a l l y record t h i s order. Several times d a i l y , pharmacy technicians review a l l active medication orders and prepare i n d i v i d u a l l y labeled drug cabinets with unit dose drugs. These drug cabinets containing medications f o r a s p e c i f i c number of patients (usually one nursing unit) are transported to the patient-care areas on medication cartsr.v. Nursing personnel on each unit are then responsible f o r administering and charting the medication delivered from the pharmacy. These cabinets contain enough doses of each ordered drug to be administered over a two to twenty-four hour period. One of the i n i t i a l attempts i n c e n t r a l i z e d unit dose d i s t r i -bution was a p i l o t study reported at the University of F l o r i d a Teaching Hospital(35). The s i g n i f i c a n t features of t h i s project were the use of supportive personnel under pharmacy supervision to prepare medications and the d i s t r i b u t i o n of a short drug monograph, "Pharmacy Notes f o r Nurses" with each dose. 10 Soon after the Florida project, reports were published of an extremely comprehensive and detailed system at the University of Arkansas Medical Center(18,36,37,38). This system demonstrated the value of punch cards and electronic data processing equipment to control drug order information and to schedule doses. The data processing equipment and teletype terminals located in the nursing stations also were used to print frequent patient drug summaries for the nursing staff. Unfortunately, the lack of continuing financing resulted in the discontinuation of this experimental system(39). The f i r s t total hospital centralized unit dose system was implemented at the University of Kentucky Medical Center(6). Started in 1965, this program emphasized the value of drug usage data, non-professional personnel and data processing in production methods. These three major studies also identified the need for commercially available unit dose packaged medications. Decentralized Unit Dose Distribution. The decentralized system utilizes one or more small pharmacy substations or s a t e l l i t e units located in the patient-care areas of the hospital. These decentralized stations are normally established to serve one complete floor of the hospital'.or a group of nursing units usually involving from ninety to 145 beds(28,29,40). Complete operation of the satellites is primarily maintained on a one (eight hour) or two shift basis (sixteen hours) requiring one pharmacist and one technician per s a t e l l i t e per shift. It should be noted, however, that a central 11 pharmacy i s s t i l l usually required for prepacking, administrative and bulk storage functions. Drug d i s t r i b u t i o n procedures are e s s e n t i a l l y i d e n t i c a l to the c e n t r a l i z e d unit dose system. The major benefits of improved communication, drug information, and s u r v e i l l a n c e services anticipated from the decentralized system are the d i r e c t r e s u l t of having the pharmacist and medications i n close proximity to the nursing stations and patients. The prime developmental studies of the decentralized system were reported at the Memorial Hospital of Long Beach i n 1961(41), U n i v e r s i t y General Hospitals at the Un i v e r s i t y of Iowa i n 1964(42) and the Un i v e r s i t y of Wisconsin Hospitals i n 1965(43). An e s s e n t i a l feature of the experimental system at the University of Wisconsin i s that i t was modified i n 1967(26) to eliminate pharmacy substations. Mechanical handling of medications was accomplished i n a c e n t r a l unit dose dispensary. However, the pharmacists remained i n the patient-care areas, supported by a ce n t r a l drug information center, to maintain drug s u r v e i l l a n c e and information ser v i c e s . This subsequently led to the development of a form of "combination" unit dose system described at the U n i v e r s i t y of Michigan Medical Center i n 1969(24) and the Ohio State Uni v e r s i t y Hospitals i n 1970(25). The pharmacists are assigned decentral-i z e d drug,information, s u r v e i l l a n c e and d i s t r i b u t i o n r e s p o n s i b i l i t i e s but a l l doses are prepared and d i s t r i b u t e d from a c e n t r a l pharmacy. The unit dose d i s t r i b u t i o n methods — c e n t r a l i z e d , decentral-ized, or "combination" — o f f e r many improvements f o r the d e f i c i e n c i e s i n the t r a d i t i o n a l d i s t r i b u t i o n system. S l a t e r and Hripko(44) perhaps have 12 outlined best the potential advantages to pharmacy and nursing in a unit dose distribution system: 1. Pharmacy personnel are freed for increased patient involvement; 2. Decreased pilferage, decreased revenue loss and increased control result; 3. Crediting returned drugs is virtually eliminated; 4. Complete patient medication profile is available in the pharmacy for review to aid physicians and nurses in drug therapy; 5. Unused drugs may be returned and reused since packages have never been opened; 6. Unit-dose packages contain complete identification of drug, lot number and expiration date up to the time of administration to the patient; 7. Pharmacists' time is better ut i l i z e d ; 8. Pharmacy workload activity i s more constant throughout the day; 9. A copy of the physician's original order form should eliminate a l l transcribed orders and r e f i l l orders; 10. Exact quantities can be dispensed; nursing errors in pouring liquids and f i l l i n g syringes should be eliminated; 11. Increasingly complex reconstitution problems for injectables and suspensions pose problems. They can be properly handled in the pharmacy. The pharmacist is more aware than nurses of s t a b i l i t y , compatability, proper reconstitution, vehicles and storage requirements; 12. Inventory management is facilitated by control of dated drugs; 13. Multiple checks for accuracy are possible. 13 The disadvantages of the unit dose system are few and may be a t t r i b u t e d to d i f f i c u l t y i n the f a m i l i a r i z a t i o n with the new system by nursing and pharmacy personnel. Therefore, s t r i c t attention to planning and the development of e f f e c t i v e p o l i c i e s and procedures i s required. The expense of the i n i t i a l f i n a n c i a l investment i n pharmacy a l t e r a t i o n s and equipment(44) which may be s u b s t a n t i a l would appear, however, to be worthwhile i n the long run of operation. Other Contemporary Features i n Drug D i s t r i b u t i o n . Several developments r e l a t e d to the unit dose d i s t r i b u t i o n system have been reported recently. Beste(45), L a t i o l a i s ( 4 6 ) and Derewicz and Zellers(27) have i d e n t i f i e d the need f o r pharmacy to be responsible f o r the complete drug d i s t r i b u t i o n cycle including the administration of medications to p a t i e n t s . Two approaches have been described. A team of c e n t r a l i z e d medication administration nurses employed by and under the supervision of the Director of Pharmacy Services i s u t i l i z e d at Providence H o s p i t a l , Seattle(45). Secondly, at the Ohio State U n i v e r s i t y Hospitals, nursing personnel deny that the administration of drugs i s a symbol of status f o r any type of nurse(10). The philosophy adopted at t h i s i n s t i t u t i o n i s that i t " . . . was a waste of nursing education to allow a r e g i s t e r e d nurse to function i n only t h i s one aspect of patient care when she was prepared to f u l f i l a l l the functions of professional nursing"(10). Therefore i t was decided to assign the r e s p o n s i b i l i t y of a l l tasks i n medication procedures to the pharmacy department and nonprofessional personnel trained and supervised 14 by pharmacists would administer medications. This l a t t e r type of system, however, may require the pharmacy to undertake extensive recruitment, s e l e c t i o n , and t r a i n i n g programs for pharmacy technicians — programs which also could be implemented by the nursing department. The introduction of unit dose packaging has subsequently l e d to the development of drug dispensing machines. Two examples of these systems are the manual Brewer drug stations(47) and the automated remote "Meditrol" dispensing system(48). These dispensing units located i n the patient care areas require nurse, patient and drug i d e n t i f i c a t i o n before they are activated. A record of every transaction i s made on a print—out form so that pharmacy con t r o l and reduction of inventory losses are major b e n e f i t s . However, the low quantity of drug orders processed by the machine(48), the l i m i t e d v a r i e t y of medications that can be dispensed(47) and malfunctions(48) would appear to l i m i t the usefulness of these u n i t s . Beste(45) has stated that Brewer machines were not the answer at Providence H o s p i t a l , S e a t t l e . They " . . . aid i n departmental accounting but not ac c o u n t a b i l i t y " and they place " . . . a d d i t i o n a l r e s p o n s i b i l i t y f o r medications on nurses already burdened with a m u l t i p l i -c i t y of duties" (45). The unit dose d i s t r i b u t i o n system has i d e n t i f i e d the value of e l e c t r o n i c data processing (E.D.P.) to speed information handling and reduce manual r e p e t i t i v e tasks. Although E.D.P. was i n i t i a l l y applied to admini-s t r a t i v e tasks(49), i t also has been reported f o r such functions as formulary preparation(50,51,52), maintaining narcotic and con t r o l l e d drug 15 records(53,54), inventory controls(53,55,56,57) and generating operating and budget reports(56). Recently, however, electronic data processing has been described in the actual drug distribution process, especially the unit dose method. Programming of the unit dose distribution system for E.D.P. is fa c i l i t a t e d since pharmacy controls and procedures are much more rigi d and expl i c i t l y defined compared to the traditional system. A developmental medication subsystem of a total "Automated Hospital Information System" (AHIS) was reported by Slavin(58) for the Veterans Administration Hospital, Washington D.C. This system was designed for the provision of twenty-four hour per day, "real-time" patient-care data. The input of medication orders to the computer is by way of a programmed keyboard. A l l medication orders are automatically checked for stop order renewals and hourly medication schedules are generated. The f i l e s of this subsystem which have received priority in the study are the medication order, ward medication administration control and the formulary f i l e s . Since 1968, the University Hospital at the University of Saskatchewan has been actively involved in the design of a comprehensive computer-based decentralized unit dose system(59). This project serving 124 beds of the 550-bed hospital by September of 1970 ut i l i z e d one sa t e l l i t e unit. A l l input to the computer is through the use of a cathode ray tube display and keyboard. The types of output that can be generated are discharge drug summaries, hourly drug administration l i s t s for the nursing units, daily "P.R.N." l i s t s , narcotic labels, renewal l i s t s and 16 patient drug p r o f i l e s ( 6 0 ) . • This decentralized s a t e l l i t e i s i n operation f o r sixteen hours per day and i s s t a f f e d by one pharmacist and a technician per s h i f t . An extremely important requirement i n the development of a computer-assisted system would appear to be the necessity to c l e a r l y evaluate the t r a d i t i o n a l procedures. The i n e f f i c i e n t and non-productive tasks of the conventional system must be eliminated before any attempt i s made to u t i l i z e e l e c t r o n i c data processing methods(61). The Consequences of Unit Dose D i s t r i b u t i o n . Perhaps the major s i n g l e f a c t o r determining the f e a s i b i l i t y or success of the implementation of a unit dose drug d i s t r i b u t i o n system i s the economic consideration. Frequently, t h i s evaluation i s based only upon the cost of a drug i n a single unit package, the expenditure f o r a d d i t i o n a l equipment and supplies and an increased budget f o r pharmacy personnel. These variables have been shown to increase(62,63). However, i t cannot be assumed that the pharmacy budget i s the only factor which determines the cost of the h o s p i t a l drug d i s t r i b u t i o n system(64). The nursing component also represents a prime expense i n the cost of a drug d i s t r i b u t i o n system. In addition, p o t e n t i a l v a r i a t i o n s i n inventory l e v e l s , loss due to "shrinkage" and drug d e t e r i o r a t i o n must be evaluated. In summary, the economic r e s u l t s of the unit dose system may only be deter-mined by analyzing the "trade-off" that occurs due to the expected decrease i n cost of the nursing component of drug d i s t r i b u t i o n versus the anticipated increase i n pharmacy expenditures. 17 The r e s u l t s of studies published recently refute the claim that unit dose d i s t r i b u t i o n costs more to operate than the t r a d i t i o n a l system. For example, S l a t e r and Hripko(44) reported an estimated annual saving of $23,168 from the r e s u l t s of a decentralized unit dose project. Their f i g u r e was based on savings i n nursing labor cost compared to ad d i t i o n a l expenditures f o r pharmacy labor and equipment. When the h o s p i t a l converted to t o t a l unit dose, an appended study revealed that the new d i s t r i b u t i o n system contributed s i g n i f i c a n t l y to a h o s p i t a l saving of more than $100,000 per year(65). At the 600-bed Buffalo General H o s p i t a l , Yorio and coworkers projected a saving of $0.17 per patient day from a t o t a l h o s p i t a l decentralized unit dose system(30). The cost of nursing personnel a c t i v i t i e s i n th i s unit dose system were approximately $0.50 per patient lower than the t r a d i t i o n a l system. In comparison, pharmacy personnel and the standard departmental costs at Buffalo General H o s p i t a l were only $0.31 per patient day higher i n the unit dose system. At the Memorial H o s p i t a l of Long Beach, Smith and Mackewicz(29) determined that t o t a l drug d i s t r i b u t i o n costs per patient day increased by $1.59 a f t e r the implementation of the PACE (Patient Care Environment) decentralized unit dose system. However, due to an increase i n nursing workload and h o s p i t a l patient days, i t was projected that t h i s new system had overcome the need for an a d d i t i o n a l 17.5 nurses. When t h i s f a c t o r was.considered, a cost saving of $0.49 per patient day or annual h o s p i t a l saving of $56,000 could be anticipated(29). In the c e n t r a l i z e d unit dose study of 204 beds at Providence H o s p i t a l , Beste(45) projected a decrease of 1.5 percent i n combined nursing 18 salaries and pharmacy costs for a total hospital system. This amounted to a reduction of approximately.$0.32 per patient day in drug distribution costs. Hynniman(63) has reported on comparable distribution costs of the centralized system at the University of Kentucky Medical Center and four hospitals operating traditional distribution systems. A comparison of the total annual costs of the drug distribution systems showed that the University of Kentucky's was much greater when the other hospitals were adjusted for the number of patient days. However, when factors such as hours of service, drug loss due to wastage, pilferage and deterioration and doses per patient day were considered the unit dose system at the Medical Center compared very favorably to the traditional system. An important feature of the unit dose distribution system which i s not reflected in nursing or pharmacy personnel labor costs is the actual annual drug expenditure. Total drug expenses are erroneously correlated to mean drug usage within a hospital. However, when nursing unit and pharmacy drug inventories and physicians' medication orders are compared to the actual cost of drugs administered to patients or credited returned drugs, a factor known as "shrinkage" (pilferage, wastage and drug deterioration) becomes readily apparent. With reference to this, very few hospitals have any idea of the magnitude of the problem. In a comparison of the actual drug balance with the theoretical balance on nursing units, Barker and Heller(5) reported that annual savings due to elimination of drug losses would have amounted to about seven times the value of the average inventory investment at the University of Arkansas i f their experimental system had continued. H i l l and coworkers(66) deter-mined that the sa t e l l i t e unit dose system at the Orange County Medical 19 Center would r e s u l t i n an annual saving of $40,000 from a reduction i n inventory l o s s . A reduction i n drug cost of about 36 percent was thought to be due to decreased p i l f e r a g e and wastage r e s u l t i n g from the use of unit dose packaging and better pharmacy con t r o l at the University H o s p i t a l i n Saskatoon(67). Increased pharmacy control reportedly could have resulted i n a reduction i n the purchase of diazepam from 54,000 to 16,500 tablets representing a p o t e n t i a l cost saving of $1575 at the Western Carolina Center, North Carolina(31). S i m i l a r l y , Beste(45) noticed an 85 to 90 percent decline i n i n s u l i n purchases a f t e r the implementation of the unit dose d i s t r i b u t i o n system. The p o t e n t i a l f o r increased drug co n t r o l by the pharmacy department as a r e s u l t of factors such as p i l f e r a g e , wastage and drug d e t e r i o r a t i o n should not be underestimated. The preceding reports of the economic impact of unit dose d i s t r i b u t i o n have primarily considered only the immediate r e s u l t s of the system i n the h o s p i t a l s . However, a report e n t i t l e d "Study of Health F a c i l i t i e s Construction Costs" by the United Stated General Accounting O f f i c e has analyzed the twenty-five year l i f e - c y c l e cost of the unit dose d i s t r i b u t i o n system(68). In t h i s study, the.unit dose system was evaluated against a mechanical dispensing system i n which drug dispensing machines are located on each nursing unit and a t o t a l ward stock system. Factors such as h o s p i t a l census, workload, labor costs, drug costs, maintenance and operations, supplies costs, space and construction costs were analyzed from 1971 to 1996. The recommendation of t h i s report 20 states: "Based on the results of the life-cycle cost/benefit analysis, the recommended pharmacy system for the reference hospital is the unit dose drug distribution system when savings in nursing time are considered. The analysis indicated that this system has the lowest life-cycle cost of a l l the systems evaluated in a l l discount and inflation rate combinations tested plus the benefits of lower dosage error rates and increased patient charting accuracy"(68). The implementation of a unit dose distribution system and i t s effect on medication errors has been well-documented. In the comparison of the unit dose system at the University of Kentucky Medical Center with four hospitals operating traditional distribution systems, Hynniman(69) reported an error rate of 3.5 percent in the unit dose system against a rate from 8.3 to 20.6 percent in the traditional systems. The decentralized unit dose study at the University Hospitals, University of Iowa, showed the error rate declined from 2.2 percent in the prior conventional system to 0.5 percent in the new system(70). Similarly during the control period at the University of Arkansas Medical Center an error rate of 31.2 percent was. recorded with the traditional system(39). After the implementation of the unit dose system this figure was reduced to 13.4 percent. When "wrong time" and "wrong brand" errors were excluded this unit dose system demonstrated an error rate of 1.9 percent(39). Although the c r i t e r i a for error in these studies may d i f f e r , significant reductions in medication errors have been shown with the unit dose systems. Ideally, the potential for increased patient safety as a result of this factor should be considered to be as important as any economic benefits of the unit dose system. 21 Unit Dose Distribution in Canada. The literature reflects that Canadian hospitals have not developed unit dose distribution systems at a rate similar to that in the United States. A major reason for this is the lack of commercially available drugs in single unit packages in Canada. In one study, only 20.8 percent of the drugs administered could have been purchased in unit dose packaging(71). The computer-based decentralized unit dose system at the University Hospital, University of Sakatchewan(60), has pioneered the study of unit dose in Canada. Recently, however, several other Canadian unit dose projects have substantiated the benefits claimed by studies in the United States. At the Camp H i l l Hospital, Halifax, 0*10016(72) and Kearns(73) evaluated the cost effect of unit dose distribution in a 53-bed extended care area on an eight hour per day and twenty-four hour per day basis. A total daily drug cost saving of $0.39 (materials and labor) for the fifty-three patients served by the twenty-four hour unit dose system was calculated in comparison with a combined traditional-unit dose system. This saving in drug cost was due mainly to a reduction in the quantity of medication at the nursing station(73). In a unit dose study in an extended care area (33 beds) of the Vancouver General Hospital, a decrease in drug cost per patient day from $0.29 to $0.26 was noted(71). Between eight and ten hours per day of pharmacy personnel time (pharmacist and technician) were projected to be required to implement this system .to a total patient population of 198. A saving of 11.7 hours in nursing time due to the reduction of many medication-related activities could be anticipated i f the system 22 were to be provided to the en t i r e patient population(71). A one-month p i l o t study on a s u r g i c a l unit at Sunnybrook H o s p i t a l , Toronto, noted a 25 percent reduction ($1.56 to $1.18) i n per diem drug costs during the unit dose period compared to the average per diem cost f o r the preceding twelve months under a t o t a l f l o o r stock system(74). A projected saving i n t o t a l nursing time of 7.6 hours per day for the 22-bed area was calculated f o r t h i s unit dose system. The authors also state that 60 percent of medication errors which would have been unnoticed i n the previous system were prevented by the unit dose system and the pharmacist's input at the f l o o r l e v e l . An important influence i n the progress of unit dose d i s t r i -bution i n Canada w i l l be the proposed "Study of Unit-Dose Drug D i s t r i -bution i n Canadian Hospitals". In 1970, the Task Force on Operational E f f i c i e n c y i n Hospitals concluded that the present i n t e r n a l drug d i s t r i b u t i o n systems i n Canadian hospit a l s are f a r from s a t i s f a c t o r y , that e f f o r t s to f i n d an improved system are long overdue, e s p e c i a l l y i n regard to patient safety and recommended the unit-dose packaging system be introduced i n at l e a s t f i v e h o s p i t a l s i n Canada(75). The objectives of the m u l t i d i s c i p l i n a r y study group analyzing the unit dose d i s t r i b u t i o n system are: "1. To improve patient safety and reduce medication e r r o r s . 2. To reduce the amount of time spent by nurses on routine medication tasks. 3. To improve the u t i l i z a t i o n of pharmacists through the provision of drug information to the nurse and physician. 4. To compare the costs of pharmacy services under the t r a d i t i o n a l and unit-dose systems"(76). 23 The College of Pharmacy, University of Saskatchewan, i n conjunction with the Canadian Society of H o s p i t a l Pharmacists, has received a National Health Grant to carry out the f i r s t phase of t h i s three-year project(77). In summary, the reports of the unit dose d i s t r i b u t i o n system i n Canada and the United States demonstrate that i t o f f e r s several economic advantages when compared to conventional methods of h o s p i t a l drug d i s t r i b u t i o n . In addition, the p o t e n t i a l f o r greater c o n t r o l over drugs by the pharmacy department, the lower incidence of medication errors and the reduction i n time spent by nursing personnel i n medication-related a c t i v i t i e s i n d i c a t e s that, at present, there i s no other reasonable a l t e r n a t i v e to t h i s method. C. Intravenous Admixture Preparation. The preparation of intravenous (I.V.) admixture solutions i n h o s p i t a l s has t r a d i t i o n a l l y been performed by f l o o r nurses, physicians or s p e c i a l I.V. therapy team nurses. The pharmacists' r e s p o n s i b i l i t y i n t h i s area, however]; has been frequently expressed(78,79) . "Few nurses would ever attempt to compound even simple mixtures intended f o r t o p i c a l or o r a l use; yet, today they r e g u l a r l y compound prescriptions f o r complex, potent drugs intended for intravenous i n f u s i o n where the drug action i s instantaneous"(79). The i n e f f i c i e n c i e s and hazards of nursing personnel's involvement i n these procedures are i d e n t i c a l to 24 the i n e f f i c i e n c i e s and hazards of t h e i r present p o s i t i o n i n drug d i s t r i b u t i o n . The amount of time required by nurses to prepare these s o l u t i o n s , the p o t e n t i a l f o r medication errors and the lack of knowledge by nurses of factors such as drug s t a b i l i t y and compatibility are v a l i d reasons f o r pharmacy to assume d i r e c t r e s p o n s i b i l i t y i n t h i s area. In a recent study i n a 350-bed h o s p i t a l , 21 percent of admixtures were compounded i n c o r r e c t l y ( 8 0 ) . In t h i s h o s p i t a l , by p o l i c y , any nurse could prepare to administer any parenteral admixture except those containing a n t i n e o p l a s t i c agents. Errors reported included wrong drug or s o l u t i o n , wrong dosage, unordered drug and incompatible drugs. The study fur t h e r reported that 14 percent of the medication cards were i n error and one-third of the medication cards made by ward clerks and not checked by a nurse were i n error. The study concluded by i n d i c a t i n g that approximately one-half of the labels on the admixtures were judged incomplete with regard to information required(80). The benefits anticipated from a pharmacy-controlled I.V. admixture service include: "1. The preparation of parenteral f l u i d s with .medication by the most expert person a v a i l a b l e i n the area of pharmaceuticals. 2. The elimination of preparing solutions with additives under poor environmental conditions i n heavily congested nursing units. 25 3. The accuracy of dosage of additives which can better be assured by the pharmacist than i s possible to con t r o l i n a l l s i t u a t i o n s when additives are cared f o r by physicians and nurses under great pressure of time. 4. The detection of inc o m p a t i b i l i t y of drugs and p a r t i c u l a t e matter before issue f o r use. 5. The nurse (and the physician under some circumstances) w i l l gain some time f o r more appropriate patient-centered a c t i v i t i e s " ( 7 8 ) . Several approaches have been reviewed i n the l i t e r a t u r e f o r the implementation of an intravenous admixture service i n pharmacy departments. The s p e c i f i c system selected depends to a great extent on the basic drug d i s t r i b u t i o n system i n the h o s p i t a l . For example, i n the decentralized unit dose systems of the University of Iowa, University Hospitals(70), Johns Hopkins Hospital(27) and the Buffalo General Hospital(30) intravenous admixture solutions are prepared i n the s a t e l l i t e pharmacy units by pharmacy personnel. When the preparation of these solutions i s c e n t r a l i z e d , the involvement of the pharmacy may vary. Holysko and Ravin(81) and Wenger and Kabat(79) have reported services where pharmacists receive the admixture order and prepare the s o l u t i o n . Floor nursing personnel are responsible for administering the sol u t i o n s . A twenty-four hour c e n t r a l i z e d pharmacy I.V.;service has been reported by Schwarz(82). In t h i s system pharmacists prepare admixture solutions which are administered by an I.V. nursing team. Comprehensive intravenous admixture preparation services have been described by Wuest(83) and Pulliam and Upton(84). In 26 these systems, an I.V. Therapy Nursing Team under the d i r e c t super-v i s i o n of the pharmacy prepare and administer admixture so l u t i o n s . Pharmacists in t e r p r e t the physician's o r i g i n a l order, check on drug s t a b i l i t y and compatibility problems and make the f i n a l check of the s o l u t i o n . The I.V. Therapy Nursing Team i s also responsible f or the administration of blood and blood products and hyperalimentation so l u t i o n s . However, few l i t e r a t u r e reports have dealt s p e c i f i c a l l y with the i n t e g r a t i o n of a unit dose d i s t r i b u t i o n system and an i n t r a -venous admixture service. The pharmacy admixture programs are t r a d i t i o n -a l l y considered d i s t i n c t from the other d i s t r i b u t i o n system. Like the unit dose d i s t r i b u t i o n system, the e f f e c t of a pharmacy admixture service on nursing time has been marked. In a 522-bed h o s p i t a l , Ravin and coworkers(85) estimated the t o t a l nursing time saved to be 4000. man-hours from a two year pharmacy admixture service. This resulted i n the addition of only one pharmacist to the s t a f f . In a four week study on two nursing units (85 beds), Wenger and Kabat(79) estimated that the nursing time saved by the pharmacy service would have amounted to three f u l l - t i m e nursing p o s i t i o n s . The t o t a l h o s p i t a l (300 beds) addi t i v e program at St. Francis H o s p i t a l , C i n c i n n a t i , was estimated to save about 4.7 nursing s t a f f per day as a r e s u l t of the el i m i n a t i o n of intravenous therapy procedures from f l o o r nurses(86). The l i t e r a t u r e indicates that no s p e c i f i c admixture service can be considered f or a l l h o s p i t a l s . The type of program i s dependent on factors such as h o s p i t a l c h a r a c t e r i s t i c s , pharmacy s t a f f i n g , budget 27 and the degree of control desired by the pharmacy. The i n i t i a l investment of implementing a pharmacy supervised admixture service cannot be considered a serious impediment in view of the potential benefits that may result in savings in nursing time and increased patient safety. D. Drug Surveillance. Prospective or "real-time" monitoring of drug selection and use probably is the pharmacists' ultimate contribution to patient care. The identification of the potential hazards in drug therapy such as adverse drug reactions, medication errors, drug hypersensitivity, and irrational drug usage leading to high costs of therapy has prompted this specialized pharmacy service. The magnitude of the problem of drug reactions has been reported by Melmon(87): "Modern therapeutic agents have contributed favorably to the physician's 'ability to influence the course of many diseases. Their use has also created a formidable health problem: 18 to 30 percent of a l l hospitalized patients have a drug reaction(88,89), and the duration of their hospitalization is about doubled as a consequence (88,89,90,91). In addition 3 to 5 percent of a l l admissions to hospitals are primarily for a drug reaction(88,92), and 30 percent of these patients have a second reaction during their hospital stay. The economic consequences are staggering: one seventh of a l l hospital days i s devoted to the care of drug toxicity, at an estimated yearly cost of $3,000,000,000"(93). Melmon(87) further states that: "If most drug reactions resulted from hypersensitivity, idiosyncrasy or the inevitable risk assumed when toxic drugs are used . . ., one could lament the facts, being powerless to change them. However, classic reactions make up less than 20 to 30 percent of drug reactions(91,94); the remaining 70 to 80 percent are predictable. Most of these are preventable without compromise of the 28 therapeutic benefits of the drug." The overburdened physician cannot maintain pace with the current explosion of drug information. The nurse, too, i s already performing many non-nursing functions which tax her time. The pharmacist i s , therefore, the health p r o f e s s i o n a l by way of education to assume the r e s p o n s i b i l i t y of assembling, evaluating and disseminating drug information to support drug s u r v e i l l a n c e services within the h o s p i t a l . The economic implications of inappropriate or i r r a t i o n a l drug therapy has been reported by Roberts and Visconti(95) and Vance(96). In a study of 340 patients to evaluate systematic a n t i m i c r o b i a l therapy, Roberts and V i s c o n t i showed that nearly 13 percent of the therapies were judged r a t i o n a l , 66 percent i r r a t i o n a l and 22 percent questionable (95). The t o t a l cost of the an t i m i c r o b i a l drugs i n t h i s study amounted to about $18,200, of which 76.8 percent was spent on i r r a t i o n a l therapy. In a prospective and retrospective study of the re s u l t s of drug monitoring at Lion's Gate H o s p i t a l , North Vancouver, active drug s u r v e i l l a n c e r e s u l t e d i n a 48 percent decrease i n the mean cost of antimicrobial drugs to the hosp i t a l ( 9 6 ) . These studies indicate that active drug u t i l i z a t i o n monitoring may s i g n i f i c a n t l y reduce the cost of therapy within h o s p i t a l s . Like the intravenous admixture programs, drug s u r v e i l l a n c e services may be pre-determined by the drug d i s t r i b u t i o n system within the h o s p i t a l . One of the prime purposes of locating a pharmacist i n the patient-care areas of the decentralized and "combination" unit dose 29 systems i s to r e g u l a r l y review drug information requests from medical and nursing personnel. Frequently, however, these pharmacists are s t i l l responsible f o r many drug d i s t r i b u t i o n duties(24,25,43). B e l l and coworkers(97), however, have described a drug information and s u r v e i l l a n c e program which i s operationally segregated from the drug d i s t r i b u t i o n system at Mercy H o s p i t a l , Pittsburgh. What are the r e s p o n s i b i l i t i e s of a pharmacist i n a drug s u r v e i l l a n c e program and what information sources and tools are at his disposal? The i d e n t i f i c a t i o n of current drug u t i l i z a t i o n reviews has corresponded with the development of drug information centers i n some hospitals(98,99,100). Centers such as these are highly desirable to maintain current information from medical and pharmacy journals and to. provide basic reference texts on medical and pharmaceutical subjects. The prime source of information on drug u t i l i z a t i o n within the h o s p i t a l i s the medical chart. To consolidate and review information from the patient chart a v a r i e t y of forms such as "Pharmaceutical Service Records" (101), "Patient Drug Summaries"(97), and "Laboratory Test Summaries"(97) have been developed. I f a p o t e n t i a l problem i s observed by the pharmacist a "Drug Information Communication Sheet"(97) may be used to relay t h i s information to the physician. The question, however, of who to monitor and what to monitor i s not r e a d i l y apparent. Several authors have i d e n t i f i e d the need to e s t a b l i s h s p e c i f i c c r i t e r i a or p r i o r i t i e s f o r drug s u r v e i l l a n c e services(102,103). These are necessary to reduce the amount of time required by the pharmacist to review therapy i n uncomplicated medical and s u r g i c a l patients. A 30 surveillance program in which such c r i t e r i a have been used has been provided by the pharmacy department of the Lion's Gate Hospital, North Vancouver, B.C. In addition, drug monitoring is effectively integrated with the distribution system. A drug profile maintained by nursing personnel on the physician's order form is used to i n i t i a l l y identify patients for more intensive drug review. Pharmacists then follow-up the case using a detailed drug profile, a drug communication sheet, i f necessary, and the medical chart on the ward. In this manner, potential problems such as drug interactions, adverse drug reactions, drug hypersensitivities, and high costs due to irrational therapy may likely be reduced or prevented. E. A Specific Situation. An analysis of the literature reflects that there is no established pattern for the complete adaptation of a pharmacy system from one hospital to another. This w i l l depend on factors such as hospital characteristics, staffing, pharmacy and nursing preferences, budget and the sophistication and degree of supervision desired by the pharmacy. However, the need for pharmacy personnel to improve the method of distributing drugs within the hospital, to supervise the preparation of intravenous therapy medication and to provide an active drug surveillance program has been identified. The potential benefits from these services in terms of more efficient u t i l i z a t i o n of personnel, increased drug control by the pharmacy, reduced nursing time involved in 31 medication-related a c t i v i t i e s , r a t i o n a l drug pre s c r i b i n g and increased patient safety are the prime goals of such progressive trends. St. Paul's H o s p i t a l , Vancouver, B.C., would appear presently to be receptive to such progressive pharmacy trends. Several major h o s p i t a l changes i n the planning stages p a r t i c u l a r l y d i c t a t e that an opportunity to introduce new programs i n drug d i s t r i -bution, drug s u r v e i l l a n c e , and I.V. admixture i s a v a i l a b l e . The s p e c i f i c future h o s p i t a l developments which are of p a r t i c u l a r importance to pharmacy planning are: 1. The h o s p i t a l i s currently a s s i s t i n g i n the develop-ment of a computer-based purchasing and inventory system. This service w i l l ! i n i t i a l l y cover items presently stocked i n the c e n t r a l supply area but i t i s a n t icipated that drug inventories w i l l eventually be included; 2. The h o s p i t a l has been projected as the s i t e to i n i t i a t e a p r o v i n c i a l drug and poison information center(104). This project i s intended to provide the required f a c i l i t i e s to update the p r o v i n c i a l Drug Formulary and poison control card monographs. It i s also anticipated that the pharmacy department of the h o s p i t a l w i l l work c l o s e l y with the s t a f f of the proposed center to provide for the drug s u r v e i l l a n c e and information needs of the patients of St. Paul's H o s p i t a l ; 3. St. Paul's Hospital i s currently i n the planning stage of a new h o s p i t a l complex. The f i r s t phase, 32 approximately four years away, w i l l involve the construction of a large base f a c i l i t y to contain the hospital's essential services. The second phase, about seven years away, w i l l include pharmacy services for the new hospital. This stage presently does not specify any details regarding location, f a c i l i t i e s or space allowance for the future pharmacy(105). The third phase (which may be included in the second phase) w i l l be the construction of the actual patient tower. The potential involvement of the pharmacy depart-ment in these planning stages is obvious. What information i s a v a i l a b l e that w i l l a s s i s t i n the pro j e c t i o n of progressive pharmacy services at St. Paul's Hospital? How can the current c h a r a c t e r i s t i c s of the h o s p i t a l be used to estimate future f a c i l i t y and s t a f f requirements f o r these services? These questions might best be answered through an analysis of other present progressive pharmacy programs to a s s i s t i n the design of comparable drug d i s t r i b u t i o n , intravenous admixture and drug s u r v e i l l a n c e services at St. Paul's H o s p i t a l . 33 STATEMENT OF PROBLEM The t r a d i t i o n a l drug d i s t r i b u t i o n methods do not adequately provide necessary drug use controls. Contemporary systems such as unit dose d i s t r i b u t i o n and pharmacy-supervised intravenous admixture programs integrated with an e f f e c t i v e drug s u r v e i l l a n c e or monitoring service o f f e r solutions to the inherent problems i n t r a d i t i o n a l h o s p i t a l pharmacy serv i c e s . However, i t would be unwise to attempt to implement these programs without an evaluation of e x i s t i n g , s i m i l a r s e r v i c e s . In addition, the present operation of a s p e c i f i c h o s p i t a l must be analyzed to i d e n t i f y i t s requirements and a d a p t a b i l i t y to these modifications. The objectives of the present study are: 1. To project the unit dose d i s t r i b u t i o n , intravenous admixture and drug s u r v e i l l a n c e services of choice i n a s p e c i f i c 5 7 5-bed h o s p i t a l based on e x i s t i n g programs; 2. To project the personnel and f a c i l i t i e s required to implement these services; and 3. To recommend a f e a s i b l e phasing schedule to achieve the proposed ser v i c e s . 34 EXPERIMENTAL METHODS A. General The experimental procedures used i n t h i s research were undertaken to accurately project the systems, personnel and f a c i l i t i e s required f o r progressive pharmacy services at St. Paul's Hospital based on unit dose drug d i s t r i b u t i o n . I n i t i a l l y , the c h a r a c t e r i s t i c s of St. Paul's Hospital were defined and the present Pharmacy Department analyzed with reference to p r o v i s i o n of e x i s t i n g s e r v i c e s . Secondly, a d d i t i o n a l information was requested from hospi t a l s i d e n t i f i e d i n the l i t e r a t u r e which were operating successful unit dose d i s t r i b u t i o n systems. F i n a l l y , s p e c i f i c approaches from the l i t e r a t u r e describing drug d i s t r i b u t i o n , intravenous admixture and s u r v e i l l a n c e programs were analyzed to determine procedures, personnel and f a c i l i t y requirements. B. St. Paul's Hospital A study was undertaken at St. Paul's H o s p i t a l to describe the c h a r a c t e r i s t i c s and services provided by the h o s p i t a l . In addition, b a s i c s t a t i s t i c s of d i r e c t importance to the Pharmacy Department were acquired. The organizational and administrative nature of the present Pharmacy Department was evaluated to consider features such as: formulary p o l i c i e s , services within the h o s p i t a l , f a c i l i t i e s , s t a f f i n g , purchasing and inventory procedures. Appropriate data and s t a t i s t i c s were obtained to compare the c h a r a c t e r i s t i c s of the operation at St. Paul's 35 H o s p i t a l with h o s p i t a l s described i n the l i t e r a t u r e . The procedures used to f a c i l i t a t e i n p a t i e n t , ward stock, n a r c o t i c and c o n t r o l l e d drug and outpatient dispensing were reviewed. The r e l a t i o n s h i p of the I.V. Therapy Service and intravenous admixture preparation to the pharmacy department was considered to i d e n t i f y the method by which a pharmacy-supervised admixture service might be provided. To conclude t h i s evaluation, the drug information, s u r v e i l l a n c e and educational programs sponsored by the pharmacy department at St. Paul's Hospital were studied. Where po s s i b l e , interviews with h o s p i t a l personnel responsible f o r each service area were conducted. The remainder of information was obtained through interviewing the Director of Pharmacy Services and through personal observation and evaluation of e x i s t i n g systems. C. General Information Survey The l i t e r a t u r e survey i d e n t i f i e d several hospitals which have implemented progressive unit dose drug d i s t r i b u t i o n systems. P o l i c i e s and procedures used to achieve the unit dose d i s t r i b u t i o n system i n these i n s t i t u t i o n s were usually w e l l documented. However, basic h o s p i t a l information was required to accurately c o r r e l a t e the l i t e r a t u r e reports with the analysis of St. Paul's H o s p i t a l . S i m i l a r l y , data such as the pharmacy department s t a f f i n g patterns,-workloads, approximate per patient day pharmacy cost and hours of service which may have been excluded from the l i t e r a t u r e reports was required. I t also was recognized that some time might have passed since the o r i g i n a l studies were published. 36 Therefore, information concerning the present status of these unit dose d i s t r i b u t i o n systems as they might d i f f e r from previous reports was d e s i r a b l e . To obtain t h i s a d d i t i o n a l information, a b r i e f general information questionnaire was mailed to t h i r t e e n h o s p i t a l s operating well-documented unit-dose d i s t r i b u t i o n systems. The ho s p i t a l s included i n the survey were: 1. University Hospitals, University of Wisconsin, Madison. 2. Ohio State University Hospitals, Columbus. 3. University H o s p i t a l , University of Michigan, Ann Arbor. 4. Kettering Memorial H o s p i t a l , Kettering, Ohio. 5. University H o s p i t a l , University of Saskatchewan, Saskatoon. 6. Memorial Ho s p i t a l of Long Beach, Long Beach, C a l i f o r n i a . 7. Temple Uni v e r s i t y H o s p i t a l , P h i l a d e l p h i a . 8. U n i v e r s i t y Hospitals, University of Iowa, Iowa C i t y . 9. Providence H o s p i t a l , S e a t t l e , Washington. 10. St. Joseph's H o s p i t a l , St. Paul, Minnesota. 11. University of F l o r i d a Teaching H o s p i t a l , G a i n e s v i l l e . 12. University of Arkansas Medical Center H o s p i t a l , L i t t l e Rock. 13. University of Kentucky Medical Center, Lexington. The questionnaire that was used i n t h i s survey i s shown i n Figure 1. The r e s u l t s were then tabulated and compared to the data obtained from the analysis of St. Paul's H o s p i t a l . D. L i t e r a t u r e Approaches To supplement the information obtained from the general survey, s p e c i f i c approaches to the implementation of unit dose d i s t r i b u t i o n , FIGURE 1. 37 QUESTIONNAIRE HOSPITAL INFORMATION 1. Beds 2. Occupancy rate (1972) 3. Average length of patient stay(1972) 4. Medical and r e l a t e d services PHARMACY DEPARTMENT 1. Hours of service 2. S t a f f i n g : a) Number of administrative personnel _ b) Number of s t a f f pharmacists _ c) Number of supportive personnel _ 3. Approximate departmental budget(1972) _ 4. Department purchases include (yes or no) a) drugs b) chemicals c) diagnostic products d) I.V. solutions e) anesthetic gases f) other medical and s u r g i c a l supplies _ 5. Approximate per patient day pharmacy cost 6. Approximate number of inpatient doses prepared per day 7. A b r i e f summary of the transportation system used by the Pharmacy department 8. A d e s c r i p t i o n of the method f o r handling: a) n a r c o t i c and controlled drugs b) intravenous solutions and additives c) inventory procedures 9. A b r i e f outline of any drug information and education programmes that take place i n the department. 38 intravenous admixture and drug s u r v e i l l a n c e systems were analyzed from the l i t e r a t u r e . In each h o s p i t a l , an attempt was made to correlate the f a c i l i t i e s , procedures, workload, or s t a f f i n g pattern with the service provided. The data and information obtained from the general information survey and the l i t e r a t u r e i d e n t i f i e d s p e c i f i c approaches and s t a f f and f a c i l i t y requirements to provide c e r t a i n unit dose d i s t r i b u t i o n , intravenous admixture and drug s u r v e i l l a n c e programs. The strengths and weaknesses of i n d i v i d u a l systems were also i d e n t i f i e d and commented upon. F i n a l l y , using the analysis of the present pharmacy services at St. Paul's Hospital and s p e c i f i c information obtained from other sources, modified drug d i s t r i b u t i o n , intravenous admixture and drug s u r v e i l l a n c e systems were proposed to introduce these progressive trends. 39 RESULTS AND DISCUSSION A. St. Paul's H o s p i t a l Analysis 1. H o s p i t a l St. Paul's H o s p i t a l , Vancouver, B.C., i s a major acute-care r e f e r r a l h o s p i t a l i n the province. Founded i n 1894 and administered f o r many years through i t s r e l i g i o u s a f f i l i a t i o n , i t i s now a government financed and regulated community i n s t i t u t i o n . The h o s p i t a l provides basic medical and s u r g i c a l f a c i l i t i e s and a d d i t i o n a l s p e c i a l t y services such as ortho-pedics, maternity, p e d i a t r i c s , a renal d i a l y s i s u n i t , neurosurgery and gynecology. St. Paul's H o s p i t a l i s a teaching s i t e f o r medical students of the Faculty of Medicine, U.B.C, interns, and residents and has also operated i t s own nursing school. The h o s p i t a l has a rated capacity of 621 inpa t i e n t beds (575 excluding bassinets). The d a i l y occupancy rate i n 1972 was about 89 percent with an average length of patient stay of 10.08 days (excluding newborns). 2. Pharmacy Department In the administrative organization of St. Paul's H o s p i t a l , the Pharmacy Department i s supervised by the hospi t a l ' s Medical Director. The pharmacy i s responsible f o r the purchasing and dispensing of medications to the hospital's inpatients and outpatients, budgeting f o r anesthetic gases, intravenous s o l u t i o n s , chemicals and diagnostic agents, and providing s t a f f 40 p r e s c r i p t i o n services. The department operates under the guidelines established by the Pharmacy and Therapeutics Committee and the Dir e c t o r of Pharmacy Services. With respect to medication usage i n the h o s p i t a l , "The members of the Medical S t a f f s h a l l acquaint themselves with and adhere to the p o l i c i e s regarding drug administration as stated i n the Hos p i t a l Formulary"(106). U n t i l about 1967, the Director of Pharmacy Services r e g u l a r l y prepared and revised a formulary following the American Ho s p i t a l Formulary Service c l a s s i f i c a t i o n . At present, there i s no s p e c i f i c h o s p i t a l drug formulary or l i s t . The h o s p i t a l has, however, adopted the current p r o v i n c i a l Drug Formulary, o r i g i n a l l y developed by the pharmacy department at Lion's Gate H o s p i t a l , to serve t h i s purpose. A d d i t i o n a l information f o r prescr i b i n g can be found i n the pharmacy section of the St. Paul's H o s p i t a l Nursing P o l i c y Manual. The pharmacy department provides d a i l y drug d i s t r i b u t i o n services to the hospi t a l ' s inpatients and departments. In addition to approximately twenty nursing units which receive ward stock and p r e s c r i p t i o n medications, other areas such as the operating rooms, emergency, out-patient department (O.P.D.), post-anesthetic recovery (P.A.R.), x-ray, c e n t r a l s t e r i l e supply, l a b o r a t o r i e s , d i e t a r y , housekeeping, p r i n t i n g , I.V. Therapy, and the power plant receive c e r t a i n supplies from the pharmacy. A summary of the cost of drug a l l o c a t i o n s , bed capacities and services of the hospi t a l ' s nursing units are given i n Table I. The pharmacy department i s located on the basement and f i r s t f l o o r l e v e l s of the h o s p i t a l and occupies an area of about 1850 sq. f t . The basement l e v e l provides storage f a c i l i t i e s f o r most drugs used i n the h o s p i t a l , 41 TABLE I. COST OF DRUG ALLOCATIONS ($) FROM PHARMACY TO NURSING UNITS** AT ST. PAUL'S HOSPITAL. Floor Nursing Unit Service Beds Inpatient P r e s c r i p t i o n s Ward Stock • Narcotic & Controlled 2nd 2SA Medicine 41 2610 580 20 2SB Medicine 29 468 500 10 2E I.G.U. 20 978 1157 35 2N Medicine 40 474 634 17 To t a l 130 3rd 3M . Surgery 32 262 558 67 3S Ped.,Activ. 49 233 229 8 3E Surgery 31 426 704 54 3N Medicine 32 360 679 21 3NN Neurosurg. 23 250 535 32 T o t a l 167 4 th 4S Urology 44 504 611 50 4E Orthopedics 46 405 468 86 4N Orthc Orthopedics 27 282 380 28 4N •E.E.N.T. 35 223 629 38 To t a l 152 5 th 5M Case Room 4 - 275 10 5W Renal Unit 7 888 1446 33 5S Surgery 41 415 826 113 Nursery Nursery 11 - 44 -5N Gynecology 43 468 672 82 T o t a l 106 6th 6S 6S Maternity OBN 31 35 93 289 19 T o t a l 66 Hosp-i t a l T o t a l 621 For month of Feb. 1973. A l l o c a t i o n s to nearest d o l l a r . 42 security storage for narcotic and controlled drugs, a bulk manufacturing area and ward stock distribution. Inpatient and outpatient dispensing is located on the main floor level. In addition, the administrative and c l e r i c a l duties of the department are maintained in this area. Standard pharmacy equipment is used for the majority of dispensing and manufacturing procedures. An electronic tablet and capsule counting machine is uti l i z e d for ward stock and narcotic drug prepackaging. Annual capital equipment expenditures for other items, however;- are usually minimal. The pharmacy department i s staffed by six licenced pharmacists and three supportive personnel who provide daily nine and one-half hour (Monday to Friday) and nine hour (Saturday and Sunday) coverage. The Director of Pharmacy Services is responsible for supervising the daily operation of the department, preparing budget and inventory records, inter-viewing pharmaceutical sales representatives and establishing pharmacy policy through the Pharmacy and Therapeutics Committee. The job functions of the five staff pharmacists are essentially identical since there i s no policy manual specifically detailing individual responsibilities. These pharmacists dispense a l l inpatient, outpatient and staff prescriptions; receive and distribute narcotic and controlled drug orders to nursing units; and handle drug information requests from medical and nursing personnel. The three supportive staff are responsible for c l e r i c a l duties, distributing ward stock items to the nursing units, some bulk compounding and restocking pharmacy medication storage areas. The pharmacy department budget purchases a l l drugs, chemicals, diagnostic products, intravenous solutions, anesthetic.gases and some 43 s u r g i c a l supplies used i n the h o s p i t a l . With reference to drugs, the general formulary guideline i s followed and no basic drug chemical i s purchased under more than one trade name. New drug products must receive approval from the Pharmacy and Therapeutics Committee before they can be used i n the h o s p i t a l . Approximately 1900 items are con t r o l l e d by the department. St. Paul's H o s p i t a l i s a member of a twelve h o s p i t a l lower mainland group purchasing arrangement i n which about one hundred drug products are tendered based on the estimated annual consumption of a l l the h o s p i t a l s . The h o s p i t a l also i n d i v i d u a l l y contracts to buy other high volume items such as contrast media, intravenous s o l u t i o n s , s e n s i t i v i t y d i s c s , and b a c t e r i o l o g i c a l media. The terms of contracts may be s p e c i f i e d i n e i t h e r a routine, blanket or standing order. Purchasing records of drugs are maintained under the pharmaceutical manufacturer rather than by i n d i v i d u a l product. A perpetual inventory i s maintained on a l l n a r c o t i c and con t r o l l e d drugs. A l l other medications are inventoried by the Di r e c t o r of Pharmacy Services annually. The 1972 pharmacy cost, including s a l a r i e s , supplies, maintenance, p r i n t i n g , and stationary and drug expenditures was $3.09 per patient day at St. Paul's H o s p i t a l . 3. Pharmacy Drug D i s t r i b u t i o n A flow chart of the present method of inpatient dispensing i s given i n Figure 2. St. Paul's Hospital uses the t r a d i t i o n a l method of drug d i s t r i b u t i o n with both personal p r e s c r i p t i o n and ward stock medications dispensed to the nursing u n i t s . A l l physicians' orders for medications, treatments or laboratory t e s t s are i n i t i a t e d on the FIGURE 2 PRESENT DRUG DISTRIBUTION SYSTEM AT ST. PAUL'S HOSPITAL 44 IF ORDER REQUIRES CLARIFICATION— TELEPHONE CONTACT MADE BY PHARMACIST DUPLICATE LABEL OR FORM 33 OR 33A USED FOR PRICING AND NURSING UNIT CHARGING PURPOSES PHARMACY CLERK FOR RECORDING PHARMACIST RECORDS VALUE OF RETURNED MEDICATIONS FROM NURSING UNIT PHYSICIAN PHYSICIAN'S ORDER FOR: -MEDICATION -TREATMENT -LABORATORY DIRECT COPY OF PHYSICIAN'S ORDER CARRIED FROM NURSING UNIT TO PHARMACY ORDER RECEIVED IN PHARMACY BY PHARMACIST AND SURVEYED FOR MEDICATIONS TO BE DISPENSED BY PERSONAL PRESCRIPTION COPY OF PHYSICIAN'S ORDER STAMPED WITH PRESCRIPTION NUMBER AND LABEL TYPED PRESCRIPTION FILLED FOR PATIENT BY PHARMACIST WITH SIX DAY SUPPLY OF MEDICATION PRESCRIPTION PLACED IN PICK-UP BOX IN APPROPRIATE NURSING UNIT SECTION NURSE NURSE DETERMINES IF MEDICATION REQUIRED FROM PHARMACY IF REFILL OF PREVIOUSLY DISPENSED MEDICATION REQUIRED NURSE COMPLETES FORM 33 OR 33A •T PRESCRIPTION RECEIVED AT NURSING STATION BY NURSE AND STORED IN MEDICATION CABINET NURSE ENTERS NEW MEDICATION ORDER ON MED. CARD, IN NURSING KARDEX AND MEDICATION ADMINISTRATION FORM MED. CARD FILED IN CARD RACK FOR NEXT ADMINISTRATION TIME MED. CARDS SORTED AND DOSES PREPARED AT MEDICATION ADMINISTRATION TIME MEDICATION ADMINISTERED TO PATIENT BY NURSE, CHARTED ON ADMINISTRATION FORM AND MED. CARD FILED FOR NEXT DOSE DISCONTINUED MEDICATIONS OR DRUGS FROM DISCHARGED PATIENTS ASSEMBLED BY NURSE AND RETURNED TO PHARMACY FOUR TIMES DAILY PICK-UPS MADE BY HOSPITAL MESSENGER AND PRESRIPTION'TRANSPORTED TO NURSING UNIT 45 physician's order form. I f a drug i s required from the pharmacy, the d i r e c t copy of the order i s removed and sent to the pharmacy v i a the h o s p i t a l messenger service. In the pharmacy, the order i s interpreted by a pharmacist and a p r e s c r i p t i o n l a b e l i s typed. A pharmacist then f i l l s the p r e s c r i p t i o n with a s i x day supply of medication. I f a r e f i l l of a previously dispensed drug i s required then the nurse completes a t r a n s c r i p t i o n of the order on a s p e c i a l form. A h o s p i t a l messenger provides de l i v e r y service of p r e s c r i p t i o n s to the nursing units approxi-mately four times d a i l y . An automatic stop p o l i c y e x i s t s f o r n a r c o t i c orders (72 hours) and i n j e c t a b l e a n t i b i o t i c s (four days) a f t e r which time a new physician's order i s required. A l l p r e s c r i p t i o n s are numbered, priced, and a record of p r e s c r i p t i o n drug a l l o c a t i o n s to nursing units i s maintained by the pharmacy c l e r k . A f t e r pharmacy hours service i s provided by a well-stocked night drug room. The night nursing supervisors have access to t h i s room to obtain medications. A record of these ac q u i s i t i o n s i s maintained i n the drug room. Nursing personnel on the wards are required to note physicians' orders, r e q u i s i t i o n p r e s c r i p t i o n s , document these orders i n the nursing kardex, medication card and administration record, prepare and administer medications and chart these drugs. The nursing units at St. Paul's Hospital have a l i b e r a l ward stock s e l e c t i o n . Nursing personnel complete the t r a v e l l i n g r e q u i s i t i o n book which i s then transported to the pharmacy by the messenger service. Injectable medications, l i q u i d s and miscellaneous items are d i s t r i b u t e d from the lower pharmacy l e v e l by the pharmacy aide while t a b l e t s and 46 capsules are d i s t r i b u t e d by a pharmacist from the main dispensary area. Ward stock items are transported from the pharmacy by h o s p i t a l messenger service or nursing unit personnel. Narcotic and c o n t r o l l e d drugs are d i s t r i b u t e d e i t h e r as ward stock or personal p r e s c r i p t i o n . Nursing units are required to r e q u i s i t i o n ward stock n a r c o t i c or con t r o l l e d drugs on a s p e c i a l form. These r e q u i s i t i o n s are received d a i l y by a pharmacist. He i s responsible for determining the authent-i c i t y of the r e q u i s i t i o n , numbering the order, preparing a narcotic r e g i s t e r , obtaining the required units of the drugs, and d i s t r i b u t i n g these items to the nursing s t a t i o n s . The pharmacist also maintains a perpetual inventory of a l l n a r c o t i c and controlled drugs. S i m i l a r l y to p r e s c r i p t i o n medications, ward stocks and narcotics and c o n t r o l l e d drugs are priced and "charged-out" monthly to nursing u n i t s . St. Paul's Hospital maintains an active Out-Patient Depart-ment (O.P.D.). Patients covered under the Department of Indian A f f a i r s or r e ceiving s o c i a l assistance from several agencies may receive medical care and medications from the O.P.D. In addition, a va r i e t y of s p e c i a l c l i n i c s such as prenatal, eye, podiatry, orthopedic and pacemaker c l i n i c s are re g u l a r l y held. P r e s c r i p t i o n t r a n s c r i p t i o n s i n t r i p l i c a t e are used to order medications for O.P.D. patients. These patients can receive a maximum of one month's supply of a p r e s c r i p t i o n from the pharmacy at St. Paul's H o s p i t a l . The pharmacy department i s also responsible f o r dispensing medications to h o s p i t a l patients who are being discharged. Again, a maximum of a one month's supply may be dispensed and the patient i s required to pay the pharmacy f o r these drugs when they 47 are received. Hospital s t a f f personnel may also receive p r e s c r i p t i o n and "over-the-counter" medications from the pharmacy department. The payment for discharge and s t a f f p r e s c r i p t i o n s i s based on the cost of drug plus 30 percent. St. Paul's Hospital i s currently maintaining several c l i n i c a l research studies. Those programs i n which i n v e s t i g a t i o n a l drugs are being used are requested to have them stored and dispensed from the pharmacy department. In add i t i o n , the in v e s t i g a t o r i s required to supply a drug protocol and other necessary information pertaining to t h e i r use. The involvement of the pharmacy department, however, does not extend beyond the storage and dispensing functions. Approximately four i n v e s t i g a t i o n a l drugs are currently being d i s t r i b u t e d from the pharmacy. During normal d a i l y s t a f f i n g (Monday to Fri d a y ) , four pharmacists are assigned to dispense in p a t i e n t , discharge, s t a f f and O.P.D. p r e s c r i p t i o n s . An ad d i t i o n a l pharmacist spends approximately the complete day assigned to narcotic and controlled drug d i s t r i b u t i o n and record maintenance. A summary of the representative d a i l y pharmacy workload i s given i n Table I I . Several observations can be made from t h i s Table with respect to pr o f e s s i o n a l a l l o c a t i o n of the pharmacists' time. F i r s t l y , of an average d a i l y workload of 215 units (inpatient, discharge, s t a f f , O.P.D., S.A.M.S. pr e s c r i p t i o n s plus eight units of "over-the-counter" sales) only about 65 percent of t h i s t o t a l i s composed of St. Paul's Hospital inpatient p r e s c r i p t i o n s . Secondly, since one 48 TABLE I I . REPRESENTATIVE DAILY PHARMACY DEPARTMENT WORKLOAD3 AT ST. PAUL'S HOSPITAL ITEM (UNITS) d MON TUES WED THUR FRI SAT SUN AVE. Inpatient P r e s c r i p t i o n 106 172 142 162 167 .". 125 85 139 Discharge and S t a f f ^ P r e s c r i p t i o n s 35 45 34 49 64 39 33 42 Ward Stock 393 234 207 205 252 2 2 189 O.P.D. Pre s c r i p t i o n s 15 17 9 30 8 2 0 12 S.A.M.S? Pr e s c r i p t i o n s 24 14 20 10 14 5 8 14 Narcotics and Control-led Drug Ward Stock 51 57 43 57 59 47 36 50 Averaged d a i l y s t a t i s t i c s for the p eriod Feb. 13 to 28 , 1973. Hospital occupancy rate during t h i s period 88 to 94 percent. Excluding an" average of eight "over-the-counter" sales per day. S o c i a l Assistance (welfare) p r e s c r i p t i o n s . A single u n i t i s one p r e s c r i p t i o n or ward stock container. 49 pharmacist i s assigned n a r c o t i c and c o n t r o l l e d drug duties, t h i s reduces the d a i l y a v a i l a b l e pharmacist manpower by 20 percent (during f u l l s t a f f days). The d i s t r i b u t i o n of these drugs and the maintenance of appropriate records i s a r e s p o n s i b i l i t y that may be delegated to supportive, non-professional personnel. F i n a l l y , another pharmacist i s responsible f o r the ward stock d i s t r i b u t i o n of tablets and capsules, although the time required f o r t h i s d a i l y a c t i v i t y i s usually minimal. This analysis of the present s t a f f i n g , p r i o r i t i e s and workload of the pharmacy department i s important i f a d d i t i o n a l s t a f f requirements are projected i n the design of new pharmacy services. 4. I.V. Therapy Service An Intravenous Therapy Service under the supervision of the Department of Nursing i s employed at St. Paul's H o s p i t a l . The I.V. therapy team, s t a f f e d by s p e c i a l l y trained registered nurses i s responsible f o r doing venepunctures, s t a r t i n g and restarting-most-intra-venous infusions administered i n the h o s p i t a l . This service also takes blood specimens f rom'/patients f o r cross-matching and administers blood and blood products to patients. I f problems develop during infusions such as i n f i l t r a t i o n or p h l e b i t i s , members of t h i s team are o n - c a l l to invest i g a t e . F i n a l l y , the I.V. Therapy Service i s responsible f o r preparing and administering a l l hyperalimentation solutions used i n the h o s p i t a l . Although not under the supervision of the pharmacy department, the proximity to the pharmacy permits nurses of the I.V. Therapy team opportunity of using the resources of the pharmacy to solve problems 50 which may be pharmaceutical i n nature. Requests for a member of t h i s service to s t a r t an i n f u s i o n with or without additives are not transmitted by the d i r e c t copy of the physician's order used by the pharmacy department. A separate r e q u i s i t i o n form i s used or verbal i n s t r u c t i o n s v i a the telephone are permitted from the nursing u n i t s . Each nursing unit receives a ward stock of the standard intravenous solutions d i s t r i b u t e d from the I.V. Therapy room. Floor nurses employed i n the various patient care areas are permitted to prepare admixture solutions. Regulations sp e c i f y i n g the techniques to be followed are covered i n the St. Paul's Ho s p i t a l Nursing Procedure Manual. Floor nurses may only administer intravenous solutions and admixture solutions by way of previously established administration sets. A flow chart of the present i n t r a -venous additive and administration system at St. Paul's H o s p i t a l i s given i n Figure 3. The I.V. Therapy Service i s s t a f f e d by nursing personnel twenty-four hours per day, seven days a week. The actual number of intravenous admixture solutions prepared and administered per day i s unknown since f l o o r nursing personnel prepare most of the admixtures. However, approximately 5000 to 6000 I.V. solutions and solutions with additives are used i n the h o s p i t a l monthly (about 160 to 200 per day). The d a i l y workload of t h i s service varies with respect to the s u r g i c a l schedule of the h o s p i t a l . In addition, approximately four patients are usually receiving hyperalimentation solutions at any time prepared by the I.V. Therapy Service. The d a i l y s t a f f schedule requires four I.V. therapists on the day s h i f t , two during the evening and one nurse f o r the night s h i f t . FIGURE 3. PRESENT I.V. THERAPY SYSTEM AT ST. PAUL'S HOSPITAL 5 1 PHYSICIAN PHYSICIANS'S ORDER FOR: -MEDICATION -TREATMENT -LABORATORY FLOOR NURSE DETERMINES IF MEDICATION REQUIRED FROM PHARMACY REQUEST FOR I.V. THERAPY NURSE I.V. THERAPY NURSE PROCEEDS TO NURSING UNIT WITH VENEPUNCTURE EQUIPMENT DIRECT COPY OF PHYSICIAN'S ORDER CARRIED FROM NURSING UNIT TO PHARMACY ' NURSE ENTERS NEW MEDICATION ORDER IN I.V. SECTION OF KARDEX AND MEDICATION ADMINISTRATION FORM I.V. THERAPY NURSE CHECKS PHYSICIAN'S ORIGINAL ORDER IF ORDER REQUIRES CLARIFICATION—TELEPHONE CONTACT MADE BY PHARMACIST DUPLICATE LABEL USED FOR PRICING AND NURSING UNIT CHARGING PURPOSES PHARMACY CLERK FOR RECORDING I PHARMACIST RECORDS VALUE OF RETURNED MEDICATIONS FROM NURSING UNIT ORDER RECEIVED IN PHARMACY BY PHARMACIST AND SURVEYED FOR MEDICATIONS TO BE DISPENSED BY PERSONAL PRESCRIPTION COPY OF PHYSICIAN'S ORDER STAMPED WITH PRESCRIPTION NUMBER AND LABEL TYPED PRESCRIPTION FILLED FOR PATIENT BY PHARMACIST PRESRIPTION PLACED IN PICK-UP BOX IN APPROPRIATE NURSING UNIT SECTION FOUR TIMES DAILY PICK-UPS MADE BY HOSPITAL MESSENGER AND PRESCRIPTION TRANSPORTED TO NURSING UNIT PRESCRIPTION RECEIVED AT NURSING STATION BY NURSE AND STORED IN MEDICATION CABINET I.V. THERAPY NURSE OBTAINS WARD STOCK MEDICATION OR PRESCRIPTION AND I.V. SOLUTION AND PREPARES ADMIXTURE FLOOR NURSE PREPARES ADMIXTURE AND/OR ADMINISTERS SOLUTION VIA PREVIOUSLY SET-UP I.V. EQUIPMENT I.V. THERAPY NURSE STARTS NEW SOLUTION OR ADMIXTURE SOLUTION SOLUTION CHARTED ON MEDICATION ADMINISTRATION FORM AND/OR INTAKE. OUTPUT RECORD IN MEDICAL CHART FLOOR NURSE MONITORS FLOW RATE AND NOTIFIES I.V. THERAPY NURSE IF PROBLEMS DEVELOP DISCONTINUED MEDICATIONS OR DRUGS FROM DISCHARGED PATIENTS ASSEMBLED BY NURSE AND RETURNED TO PHARMACY 52 5. Drug Information and Education Nursing personnel are encouraged to attempt to f i n d information related to the use of drugs from reference sources a v a i l a b l e at the nursing s t a t i o n s . I f the required information cannot be obtained, the pharmacy department i s equipped to handle most general information requests. No s p e c i f i c s t a f f member i s assigned to research drug information problems. Each patient's d i r e c t copy form of the physician's orders contains a drug p r o f i l e section. The nursing personnel are required to enter new drug orders and ind i c a t e discontinued medications before the form i s sent to the pharmacy. However, at present, the pharmacy s t a f f does not routinely survey these drug p r o f i l e s for p o t e n t i a l drug therapy problems. The d i r e c t copy i s ' e s s e n t i a l l y only reviewed for medications which are to be dispensed from the pharmacy. As mentioned previously, St. Paul's Hospital i s a teaching center f o r medical students, i n t e r n s , and nursing students. The pharmacy department also i s a c t i v e l y involved i n the education of pharmacy students. Senior year undergraduate pharmacy students i n 1972-73 received an or i e n t a t i o n to h o s p i t a l pharmacy organization and administration during t h e i r clerkship i n the department. In addition, the h o s p i t a l also of f e r s a Ho s p i t a l Pharmacy Residency t r a i n i n g program i n a f f i l i a t i o n with the Faculty of Pharmaceutical Sciences, U.B.C. The residents have studied such areas as the f e a s i b i l i t y of s a t e l l i t e pharmacy units at St. Paul's Hospital and the design and evaluation of the di r e c t copy method of physician ordering. F i n a l l y , the Director of Pharmacy Services 53 r e g u l a r l y gives an i n s e r v i c e o r i e n t a t i o n lecture concerning the pharmacy department to nursing students and new h o s p i t a l s t a f f personnel. The preceding evaluation of pharmacy services at St. Paul's Hospital i d e n t i f i e s several l i m i t a t i o n s which are the r e s u l t of the t r a d i t i o n a l approach to drug d i s t r i b u t i o n , i n t r a -venous admixture preparation and drug use control. B a s i c a l l y these l i m i t a t i o n s are r e f l e c t e d i n the amount of nursing time spent i n medication r e l a t e d a c t i v i t i e s ; the lack of controls that can be exerted by the pharmacy over h o s p i t a l drug supplies; compounding of intravenous admixtures by personnel lacking i n adequate information regarding drug c o m p a t i b i l i t i e s and s t a b i l i t y ; and, f i n a l l y , the l i m i t e d drug s u r v e i l l a n c e or monitoring r e s p o n s i b i l i t y of the pharmacy department. Therefore, i t i s recognized through t h i s evaluation that drug d i s t r i b u t i o n , intravenous admixture and drug s u r v e i l l a n c e services i n St. Paul's Hospital are subject to progressive change. I t also i s recognized that the most f e a s i b l e d i r e c t i o n f o r change can be achieved through adoption of the best features of such services evaluated i n other programs. B. L i t e r a t u r e Evaluation The survey of the l i t e r a t u r e c l e a r l y establishes that some form of unit dose d i s t r i b u t i o n system gives the pharmacist the opportunity f o r d i r e c t i n g the e n t i r e drug d i s t r i b u t i o n cycle. T r a d i t i o n a l or 54 conventional d i s t r i b u t i o n systems, i n contrast, force nursing personnel to assume much r e s p o n s i b i l i t y i n t h i s area. The features of these systems which r e f l e c t the pharmacist's lack of con t r o l include: the occurrence of medication errors at a rate of 8 to 21 percent(4); nursing personnel spending 22 to 30 percent of av a i l a b l e time i n medication-related a c t i v i t i e s ( 8 , 9 ) ; thousands of d o l l a r s i n inventory l o s t through "shrinkage"(31,66); the questionable s t e r i l i t y and accuracy of intravenous admixtures prepared at the nursing stations (80); an incidence of adverse drug reactions of 18 to 30 percent(88, 89); and the hazards and high cost of i r r a t i o n a l drug selection(95). The unit dose system, however, o f f e r s the pharmacist means to overcome these d e f i c i e n c i e s . The drug p r o f i l e that i s maintained f o r preparing doses permits the pharmacist to r a p i d l y review a patient's en t i r e drug therapy. The preparation of doses i n sing l e unit packages by pharmacy technicians precludes the need for nursing personnel to spend time i n t h i s a c t i v i t y . Since f l o o r stock supplies are r e s t r i c t e d and pharmacy receives n o t i f i c a t i o n of the fate of every dose dispensed, inventory controls should be maximized. A pharmacy supervised intravenous admixture service provides f o r the accurate preparation of these pharma-ceu t i c a l s i n a clean a i r environment. A continuing drug usage s u r v e i l l a n c e program can aid i n the i d e n t i f i c a t i o n of p o t e n t i a l therapy problems such as adverse drug reactions, drug i n t e r a c t i o n s and i r r a t i o n a l drug s e l e c t i o n . In summary, the e f f i c i e n t development and operation of these services should r e s u l t i n an equitable "trade-off" i n economic considerations when the expenditures f o r equipment and 55 pharmacy personnel are compared to benefits such as decreased nursing time for medication procedures and increased patient safety. A p r o j e c t i o n of a system of choice i s d i f f i c u l t to quantitate since factors such as h o s p i t a l s i z e , services, workload, transportation methods, number of s t a f f , hours of service and pharmacy and nursing preferences vary greatly. However, i t i s possible to analyze s p e c i f i c features of other programs to a s s i s t i n the d e s c r i p t i o n of such drug d i s t r i b u t i o n , intravenous admixture and drug usage s u r v e i l l a n c e systems f o r St. Paul's H o s p i t a l based on e x i s t i n g c h a r a c t e r i s t i c s . The purpose of t h i s study was not to quantitate the s i g n i f i c a n c e of the factors or v a r i a b l e s i n the documented i n s t i t u t i o n s but to consider each v a r i a b l e within the context of a complete system.. Accordingly, no s t a t i s t i c a l analysis of the data was attempted. C. General Information .Survey Eight of the t h i r t e e n h o s p i t a l s which were included i n the survey responded by returning a completed questionnaire. Five h o s p i t a l s have u n i v e r s i t y a f f i l i a t i o n while the remainder are p r i v a t e , community i n s t i t u t i o n s . The information from the hospitals responding to the general questionnaire was analyzed according to t h e i r s p e c i f i c approach to unit dose d i s t r i b u t i o n , namely, the c e n t r a l i z e d , decentralized, or "combination" systems. A c e n t r a l i z e d method was defined as being a system i n which a l l physicians' orders are received and interpreted i n a c e n t r a l pharmacy with unit dose medications being prepared and d i s t r i b u t e d to nursing units from that same l o c a t i o n . The decentralized 56 method u t i l i z e s one or more s a t e l l i t e units located i n patient-care areas. These pharmacy s a t e l l i t e s or substations receive and i n t e r p r e t physicians' orders and prepare and d i s t r i b u t e unit dose medications f o r a s p e c i f i c number of beds or nursing units. A "combination" method was also i d e n t i f i e d . In t h i s system, pharmacy personnel i n the patient-care areas i n t e r p r e t physicians' orders d i r e c t l y from an order book located i n the nursing u n i t . The orders are then communicated to the c e n t r a l pharmacy from which a l l unit dose medications are d i s t r i b u t e d . S p e c i f i c v a r i a b l e s i n the survey such as h o s p i t a l c h a r a c t e r i s t i c s and pharmacy workload were then analyzed. F i n a l l y , consideration was given to the s t a f f i n g pattern of the pharmacy department, hours of s e r v i c e , budget and associated s e r v i c e s . D. Drug D i s t r i b u t i o n Unit Dose Systems Analysis. A summary of the h o s p i t a l c h a r a c t e r i s t i c s , services and pharmacy workloads of the c e n t r a l i z e d unit dose ho s p i t a l s i s given i n Table I I I . The "combination" system hospitals ( i . e . University of Michigan, Ohio State University and University of Wisconsin) also are included i n t h i s table since the major d i s t r i b u t i o n procedures of t h i s method are c e n t r a l i z e d . Similar information from the decentralized unit dose h o s p i t a l s i s given i n Table IV. The h o s p i t a l s surveyed are a l l acute, short-term i n s t i t u t i o n s with general medical and s u r g i c a l s e r v i c e s . Pharmacy unit dose workloads w i l l vary depending on the extent TABLE I I I . HOSPITAL STATISTICS, SERVICES, AND PHARMACY WORKLOAD OF SEVERAL CENTRALIZED AND "COMBINATION" UNIT DOSE HOSPITALS 3 HOSPITAL SERVICES BEDS AVERAGE LENGTH OF PATIENT STAY (DAYS) % OCCU-PANCY RATE AVERAGE DAILY NUMBER OF , INPATIENTS AVERAGE NUMBER INPATIENT DOSES PER DAY AVERAGE NUMBER DOSES PER PATIENT DAY University Hospital U n i v e r s i t y of Mich-igan (Ann Arbor) General Medical Surgical 1200 11 80 960 7425 7.7 d University Hospitals Ohio State Univer-s i t y (Columbus) General Special-ties'" 1000 8.1 88 880 3700 4.2 d U n i v e r s i t y Hospitals University of Wisconsin (Madison) General Special-t i e s Ped. Hosp. 616 11.5 69.9 . 430 3100 7.2d Shands Teaching Hospi t a l , Uhiv-e r s i t y of F l o r i d a (Gainesville) Medical Surgical P e d i a t r i c s OB/GYN Psychiatry 405 7.3 72.2 292 - -St. Joseph's Hos p i t a l ;(St. Paul, Minn.) Medical Sur g i c a l OB/GYN Psychiatry 429 7.3 76.5 328 2625° 8 Providence H o s p i t a l (Seattle, Wash.) General 345 7.2 78.9 272 2200° 8.1 Results from questionnaire (p. 37); a l l information based on 1972 s t a t i s t i c s . Calculated from percent occupancy rate m u l t i p l i e d by h o s p i t a l bed capacity. Calculated from average d a i l y number of inpatients m u l t i p l i e d by average number of inpatient doses per patient day. Calculated from average number inpatient doses per day divided by average d a i l y number of inpatients. TABLE IV. HOSPITAL STATISTICS, SERVICES, AND PHARMACY WORKLOAD OF TWO DECENTRALIZED UNIT DOSE HOSPITALS 3 HOSPITAL SERVICES BEDS AVERAGE LENGTH OF PATIENT STAY (DAYS) % OCCU-PANCY RATE AVERAGE DAILY NUMBER OF , INPATIENTS AVERAGE NUMBER INPATIENT DOSES PER DAY AVERAGE NUMBER DOSES PER PATIENT DAY Temple University H o s p i t a l ( P h i l a -delphia) General O.P.D. 586 11.7 76.9 450 3300 7.3° Charles F. Kettering Memorial Ho s p i t a l (Kettering, Ohio) General 413 7.7 94.5 390 - -Results from questionnaire (p.37); a l l information based on 1972 s t a t i s t i c s . Calculated from percent occupancy rate m u l t i p l i e d by h o s p i t a l bed capacity. Calculated from average number inpatient doses per day divided by average d a i l y number of i n p a t i e n t s . 59 of floor stock and whether or not items such as narcotic and controlled drugs and intravenous additive solutions are included in the system. However, as indicated from the average number of doses prepared per patient day, workloads are essentially constant irrespective of whether the centralized or decentralized system i s used. The basic unit dose systems — centralized, decentralized and a combined system — each offer several apparent advantages. Consolidation of personnel and f a c i l i t i e s i s the major benefit derived from a centralized pharmacy system. A greater f l e x i b i l i t y in staffing of pharmacists and supportive personnel could be expected to be achieved in the centralized operation^as opposed to a decentralized method. The expense of purchasing and operating equipment in prepack-aging, dispensing, maintaining inventory, and drug monitoring also would be decreased i f utilized at a high capacity in a single location. Also, in general, delegation of responsibility might be more specifically defined in a system where information and surveillance functions are operationally distinct from distributive duties. The mandatory require-ments, however, are efficient transportation and communication methods. Improved communication, drug information and surveillance services are the prime features of decentralized systems. The benefits anticipated from this operation are the direct result of having the pharmacist and medications in close proximity to the nursing station and patient. The major weakness of the decentralized method is the fragmen-tation of the patient-unit pharmacist's responsibilities. For example, 60 the time a v a i l a b l e f o r dissemination of drug information, consultation with physicians, nurses and patients and drug usage s u r v e i l l a n c e would l i k e l y be decreased due to the d i s t r i b u t i v e duties of the substation's pharmacist and technician. Further considerations which p o t e n t i a l l y l i m i t the value of a decentralized system upon c a r e f u l analysis are: 1. I f 24 hour per day coverage i s not provided from the decentralized u n i t s , then a backup c e n t r a l pharmacy must s t i l l be operated; 2. I f a l l I.V. solutions and admixture so l u t i o n s , narcotic and controlled drugs, and other l e s s frequently used medications are not stocked i n the s a t e l l i t e pharmacies then d i s t r i b u t i o n must s t i l l be provided from a c e n t r a l pharmacy; 3. Inventory records w i l l be more d i f f i c u l t to maintain i f large quantities of medications are stored and d i s t r i b u t e d from several locations; 4. In established h o s p i t a l s , a v a i l a b l e space near nursing stations for the l o c a t i o n of decentralized units i s often minimal. U t i l i t y rooms or unused patient rooms(107) f a r from nursing stations may be employed. However, t h i s p r a c t i c e detracts from the main purpose of d e c e n t r a l i z a t i o n ; 5. Renovation costs, expenditures for equipment and h o s p i t a l space overhead cost may be s u b s t a n t i a l . Reports of construction and renovation costs f o r s a t e l l i t e units vary from $2000(28) to $17,000(108); 6. Consideration must be given to the l e g a l p o s i t i o n of the pharmacist who leaves h i s decentralized pharmacy unattended to review medical charts or consult with medical and nursing personnel. 61 The combined centralized-decentralized system i s an attempt to achieve the advantages from both systems. The pharmacist i s a v a i l a b l e i n the patient-care area for drug monitoring and information communication while at the same time consolidation of pre-packing operations and unit dose preparation by supportive personnel can be maintained i n the cent r a l pharmacy(24,25,26). The p o t e n t i a l l i m i t i n g features of t h i s system are that pharmacy personnel are required to constantly monitor physicians' order books, input medication orders to the d i s t r i b u t i o n cycle and duplicate the p r o f i l e or kardex maintained i n the central pharmacy f o r unit dose preparation. In a c t u a l i t y , the pharmacist has many of the same r e s t r i c t i n g d i s t r i b u t i v e functions as the pharmacist i n the s t r i c t decentralized operation. S t a f f i n g , hours of service and associated services f o r the cen t r a l i z e d and "combination" systems are given i n Table V. It i s apparent that no c o r r e l a t i o n can be made between the s t a f f i n g patterns of these h o s p i t a l s and t h e i r respective pharmacy unit dose workloads (Table III) or s e r v i c e s . A closer comparison, however, can be made i n the s t a f f of two s i m i l a r sized p r i v a t e , community hospita l s — one cen t r a l i z e d and the other decentralized. The decentralized system of Kettering Memorial Hospital (Table IV) employs eight pharmacists and f i f t e e n supportive personnel while the c e n t r a l i z e d St. Joseph's Hospital (Table V) u t i l i z e s f i v e pharmacists and eleven supportive personnel. The pharmacy department budgets for the hospital s surveyed varied greatly depending on whether or not s a l a r i e s , expenditures for drugs, s o l u t i o n s , anesthetic gases, diag-n o s t i c products and supplies, and h o s p i t a l overhead were taken i n t o account. TABLE V. STAFFING,..HOURS OF SERVICE AND AUXILIARY PROGRAMS FOR SEVERAL CONTRALIZED AND "COMBINATION" UNIT DOSE HOSPITALS 3 HOSPITAL BEDS STAFFING HOURS OF SERVICE PER DAY PHARMACY CONTROLLED INTRAVENOUS ADDITIVE SERVICE DRUG INFOR-MATION ADMIN-ISTRATIVE STAFF PHARMACISTS SUPPORTIVE PERSONNEL INTERNS RESIDENTS University Hospital University of Mich-igan (Ann Arbor) 1200 9 25 46 9 24 Yes Formal Drug Information Service U n i v e r s i t y Hospitals Ohio State Univ-e r s i t y (Columbus) 1000 4 31 135b 11 24 Yes Formal Drug Information Center. University Hospitals U n i v e r s i t y of Wisconsin (Madison) 616 5 25 31 15 24 Yes Formal Drug Information and Poison Control Center Shands Teaching H o s p i t a l , University of F l o r i d a (Gainesville) 405 5 6 7 4 24 Yes — St. Joseph's Hosp-i t a l (St. Paul,Minn) 429 1 5 11 - 16h Yes — Providence H o s p i t a l , (Seattle, Wash.) 345 4 - 8 i oc - 24 Yes Formal Drug Information Program Results from questionnaire (p.37); a l l information based on 1972 s t a t i s t i c s . Medication administration by pharmacy technicians. Does not include 31.3 pharmacy positions involved i n medication administration. 63 The 1972 pharmacy budgets of the two h o s p i t a l s c i t e d above, containing s i m i l a r expenses, were $1,070,000 (Kettering) and $319,240 (St. Joseph's) as reported i n t h e i r questionnaire. These two factors — s t a f f i n g and budget — further support the general impression that a c e n t r a l i z e d system can be operated more economically than the corresponding decentralized unit dose system. The advantages and l i m i t a t i o n s described would appear to indi c a t e that the cent r a l i z e d unit dose d i s t r i b u t i o n system offers the greatest e f f i c i e n c y and reduced cost with regard to personnel and f a c i l i t i e s . Noned .She j-less;;, -drug<;ugage- surve.IliLance.-.and\i information services would best be maintained by decentralized or patient-care area pharmacists with no d i s t r i b u t i v e r e s p o n s i b i l i t i e s . Based upon the evaluation of the preceding h o s p i t a l programs, a c e n t r a l i z e d unit dose medication d i s t r i b u t i o n system i s recommended fo r St. Paul's H o s p i t a l . S p e c i f i c a l l y , with reference to communication and i n t e r p r e t a t i o n of physicians' orders, the method described by McConnell and coworkers(35) at the University of F l o r i d a and Beste(45) at Providence Hospital are considered preferable to those u t i l i z e d i n the combination systems. In both cases, a d i r e c t copy of the physician's order i s sent to the c e n t r a l pharmacy where drug orders are then interpreted and recorded manually by pharmacy personnel. This recommendation i s also based on the more comparable bed capacities and s t a f f requirements (Table V) of these two h o s p i t a l s to St. Paul's H o s p i t a l . The b a s i c philosophy, however, described i n the "combination" systems(26,46,109) also i s considered e s s e n t i a l . That i s , the pharmacist should be a v a i l a b l e i n the patient-care 64 areas to provide drug information and conduct drug usage s u r v e i l l a n c e studies. Proposed Unit Dose D i s t r i b u t i o n System (a) Basic System In the proposed c e n t r a l i z e d unit dose system at St. Paul's H o s p i t a l , a l l medication orders should be received, interpreted and recorded i n the c e n t r a l pharmacy. S i m i l a r l y , preparation of a l l unit doses p r i o r to administration should be accomplished c e n t r a l l y . Nursing unit personnel are recommended to administer medications to the patients. This i s i n contrast to the practices described at the Ohio State University Hospitals(10) and Providence Hospital(45) i n which pharmacy technicians or nurses employed hy the pharmacy administer medications. Although drug administration i s a part of the t o t a l "drug d i s t r i b u t i o n cycle", i t i s f e l t that t h i s i s e s s e n t i a l l y a nursing procedure to be performed by personnel trained i n patient-care management. An extensive drug usage s u r v e i l l a n c e program and intravenous additive service also should be completely integrated with the cent r a l i z e d drug d i s t r i b u t i o n system. A summary of the present and proposed medication d i s t r i b u t i o n systems of St. Paul's H o s p i t a l i s given i n Table VI. Table V showed that the pharmacy departments: of-the^majority of hospi t a l s provide twenty-four hour per day service. However, drug d i s t r i b u t i o n s e r v i c e s , that i s the preparation of unit doses and the cart exchange procedure take place on a more r e s t r i c t e d schedule. For example, TABLE VI. SUMMARY OF PRESENT AND PROPOSED MEDICATION DISTRIBUTION SYSTEMS AT ST. PAUL'S HOSPITAL SERVICE VARIABLE PRESENT PROPOSED System T r a d i t i o n a l method of combined i n d i v i d u a l p r e s c r i p t i o n i n m u l t i -doses and nursing unit ward stock. T o t a l pharmacy co n t r o l l e d cen t r a l i z e d unit dose d i s -t r i b u t i o n system. S t a f f Nursing personnel responsible for communicating physicians' orders to pharmacy. Individual p r e s c r i p t i o n dispensing by pharmacist. Ward stock d i s t r i b u t i o n by pharmacy aide. Nursing personnel or pharmacy technician responsible for communicating physicians' orders to pharmacy. A l l physicians' medication orders recorded by pharmacist. Unit doses prepared by pharmacy technician. Hours of Service Mon.-Fri. 8.00 a.m. - 5.30 p.m. Sat.-Sun. 8.00 a.m. - 5.00 p.m. Drug d i s t r i b u t i o n service scheduled from 7.00 a.m. -11.00 p.m. On-call pharmacy resident a v a i l a b l e 11.00 p.m. - 7.00 a.m. seven days per week. 66 the i n t e r v a l between the f i r s t and l a s t cart d e l i v e r i e s at the University of Michigan Medical Center and the Ohio State University Hospitals i s approximately 8^ hours(24,110). S i m i l a r l y , the i n t e r v a l at the Un i v e r s i t y of Wisconsin Hospitals and the University of Kentucky Medical Center i s about twelve hours(26,111). Therefore, while the t o t a l pharmacy operation at St. Paul's H o s p i t a l i s recommended to be twenty-four hours per day, unit dose preparation and d i s t r i b u t i o n procedures should function on a more l i m i t e d schedule(e.g. sixteen hours). In the proposed system the term "Drug D i s t r i b u t i o n Pharmacist" w i l l be used to i d e n t i f y the p o s i t i o n responsible for receiving and i n t e r p r e t i n g a l l physicians' orders. This pharmacist also would record medication orders on the p r o f i l e forms and supervise supportive personnel. The term "Drug D i s t r i b u t i on Technician" w i l l define the support s t a f f responsible for preparing unit dose medication for administration, transporting medication carts and prepackaging. F i n a l l y , "nursing personnel" w i l l r e f e r to r e g i s t e r e d , p r a c t i c a l or student nurses working on a nursing unit delegated to administer medications. (b) F a c i l i t i e s The implementation of a unit dose d i s t r i b u t i o n system at St. Paul's Hospital would require renovations to be made to the present pharmacy f a c i l i t i e s to accommodate unit dose equipment and storage u n i t s . In a d d i t i o n , since the range of products i n Canada i n unit dose packaging i s l i m i t e d , s p e c i a l packaging materials and equipment must be purchased 67 to supplement those not commercially a v a i l a b l e . Comparable figures for the United States ind i c a t e that approximately 70 percent of tablets and capsules, 50 percent of l i q u i d s and over 40 percent of the i n j e c t a b l e s can be procured from the pharmaceutical industry i n unit dose packages(19). In addition to standard pharmacy dispensing equip-ment the following items would be required f o r the cent r a l i z e d unit dose system at St. Paul's H o s p i t a l : - medication carts (approximately 20) - medication cabinets (approximately 40) with drawers - tablet and capsule packaging machine - l a b e l i n g machine - o r a l l i q u i d f i l l i n g machine and capper - packaging supplies, Kardexes, cart supplies. To accommodate the proposed services the pharmacy should have the f a c i l i t i e s f o r r e c e i v i n g , s t o r i n g , and d i s t r i b u t i n g a l l drugs, chemicals, i n t e r n a l and external solutions and large volume intravenous f l u i d s required for patient use. Therefore, with reference to space a l l o c a t i o n , the p h y s i c a l area of the pharmacy should be separated i n t o the following areas of r e s p o n s i b i l i t y ( a n d minimum area required) : - inpatient dispensing (prepackaged unit dose) (1300 sqi f t . ) - outpatient dispensing ( i f required) (included i n above) - extemporaneous compounding (200 sq. ft,;) - prepackaging and l a b e l i n g (200 sq. f t . ) - intravenous add i t i v e preparation (150 sq. f t . ) - storage - bulk drugs (500 sq. f t . ) - n a r c o t i c and c o n t r o l l e d drugs Q^Q S q f t ) - cold storage - b a r r e l storage (150 sq. f t . ) - intravenous solutions (1000 sq. f t . ) - administrative and drug information o f f i c e s . (450 sq. f t . ) 68 A d e t a i l e d cost analysis of the implementation of t h i s proposed unit dose system at St. Paul's Hospital w i l l not be attempted since the equipment and renovations required have not been more s p e c i f i c a l l y defined. However, the expenses incurred by other unit dose h o s p i t a l s are a v a i l a b l e to estimate the proposed system cost. Medication carts with cabinets and drawers vary from $425 to $600 each(31,44). A s t r i p packaging machine may cost about $3500(112). A l a b e l l i n g machine may cost about $770(31). Oral l i q u i d f i l l i n g machines vary greatly from $800 to $4000(112). N a t u r a l l y , the exact cost w i l l depend upon the manufacturer, model and the u t i l i t y of the item. These equipment expenditures are usually depreciated over a f i v e to ten year period. (c) D i s t r i b u t i o n Procedures I n i t i a t i o n of Physicians' Orders — A flow chart of the proposed c e n t r a l i z e d unit dose system at St. Paul's Hospital i s given i n Figure 4. The d i r e c t copy of physicians's orders should be used to i n i t i a t e a l l orders i n t o the medication cycle. The form (Appendix I) evaluated by Richards(113) and currently i n use at St. Paul's H o s p i t a l i s recommended to be retained. The drug p r o f i l e s e c t i o n , however, would not be necessary since a summary of a l l medications being administered to patients would be maintained by the pharmacists i n the unit dose dispensary area. Nursing personnel would be responsible for noting the orders, recording medication orders on a "Medication Admin-i s t r a t i o n Record" (Appendix II) such as that used at the University of FIGURE 4. PROPOSED UNIT DOSE DISTRIBUTION SYSTEM AT ST. PAUL'S HOSPITAL 69 "DRUG INFORMATION COMMUNICATION FORM" COMPLETED IF NECESSARY "PHARMACY DRUG SURVEILLANCE RECORD" INITIATED OR UPDATED MEDICAL CHART PHYSICIAN NURSE PHYSICIAN'S ORDER FOR: -MEDICATION -TREATMENT -LABORATORY NURSE ENTERS MEDICATION ORDER ON "MEDICATION ADMINISTRATION RECORD" AND SETS TIME FOR NEXT DOSE DIRECT COPY 0 ORDER CARRIED UNIT TO PHARM F PHYSICIAN'S FROM NURSING ACY ORDER RECEIVED IN CENTRAL PHARMACY UNIT DOSE PREPARATION AREA BY PHARMACIST IF ORDER REQUIRES CLARIFICATION-TELEPHONE CONTACT MADE BY PHARMACIST PHARMACIST INTERPRETS ORDER AND ENTERS ORDER INFORMATION IN PATIENT "MEDICATION PROFILE WORKSHEET" NOTIFICATION AND INFORMATION FROM PROFILE GIVEN TO PHARMACIST RESPONSIBLE FOR DRUG SURVEILLANCE ON PATIENT'S UNIT "MEDICATION MEMORANDUM" COMPLETED AND PLACED IN PATIENT'S MEDICATION DRAWER MEDICATION ORDERS INITIALLY SCANNED BY DRUG DISTRIBUTION PHARMACIST ACCORDING TO CRITERIA FOR FURTHER DRUG SURVEILLANCE REGULARLY DURING SHIFT NURSE CHECKS BINDER OF "MEDICATION ADMINISTRATION RECORDS" TO DETERMINE DOSES TO BE GIVEN NURSE ADMINISTERS MEDICATION AND CHARTS IN PATIENT'S "MEDICATION ADMINISTRATION RECORD" AND SETS TIME FOR NEXT DOSE "DRUGS NOT GIVEN NOTICE" COMPLETED IF NECESSARY . AND PLACED IN PATIENT'S MEDICATION DRAWER "DRUGS NOT GIVEN NOTICE" CHARTED IN PATIENT'S "MEDICATION PROFILE WORKSHEET" T THREE TIMES DAILY PHARMACY TECHNICIANS SCAN ALL "MEDICATION PROFILE WORKSHEETS" TO DETERMINE WHICH DOSES MUST BE PREPARED FOR A PARTICULAR TIME INTERVAL CART CABINETS RETURNED TO PHARMACY BY TECHNICIAN UNIT DOSE MEDICATIONS PLACED IN PATIENT'S DRAWER BY PHARMACY TECHNICIAN NURSE RECEIVES UNIT DOSE CART MEDICATIONS PREPARED BY TECHNICIANS CHECKED BY DRUG DISTRIBUTION PHARMACIST CARTS RELEASED TO TECHNICIAN TO TRANSPORT TO NURSING UNIT ACCORDING TO STAGGERED SCHEDULE CART CABINETS EXCHANGED AT NURSING STATION 70 Kentucky Medical Center and s e t t i n g the tab scheduling device for the next dose of a drug to be administered. A l l "Medication Administration Records" of patients being served by one medication cabinet should be maintained i n the same Kardex or binder. To ensure complete accuracy i n t h i s procedure, the standard administration times for the nursing unit would be required to be i d e n t i c a l to the schedule maintained i n the c e n t r a l pharmacy f o r unit dose preparation. The copy of the physician's orders should be transported to the pharmacy by a nursing messenger or by a pharmacy technician during his medication cart d e l i v e r y period. A drug d i s t r i b u t i o n pharmacist i n the inpatient unit dose dispensing area would receive a l l physicians 1 orders. This pharmacist would be responsible f o r i n t e r p r e t a t i o n of the orders and, i f necessary, c l a r i f y i n g the order with the physician. This c l a r i f i c a t i o n would require a notice such as the "Medication Memorandum" (Appendix III) now used at St. Paul's H o s p i t a l to be sent to the nursing u n i t . Patient Medication P r o f i l e — Medication orders should then be transcribed by the drug d i s t r i b u t i o n pharmacist to a "Patient Medication P r o f i l e Work-sheet". Forms such as: those used at the University of Wisconsin Hospitals (Appendix IV) are recommended. Upon the admission of a new patient, a nursing unit would be required to furnish the following information to the pharmacy to be recorded on each p r o f i l e : patient name, room, nursing u n i t , a l l e r g i e s , admitting diagnosis or s u r g i c a l procedures, patient weight and age. The medication order t r a n s c r i p t i o n should include the following information: 71 - drug and dosage form - dose of drug - route of administration - frequency of administration - time(s) of administration - PEN reason ( i f applicable) - date of order - stop order date - cart exchange number(s) The patient's medication orders should be separated on the p r o f i l e s as to scheduled medications and non-scheduled ("PRN" and non-recurring) orders. A l l p r o f i l e s for patients served by one medication cart would be maintained i n one Kardex or binder. The patient's p r o f i l e should then be reviewed by the drug d i s t r i b u t i o n pharmacist according to the c r i t e r i a established f o r continuing drug s u r v e i l l a n c e . These c r i t e r i a are l i s t e d i n the discussion of the Drug Surveillance Service (p.104). I f more intensive monitoring i s necessary, a patient-care area pharmacist would be n o t i f i e d of the p a r t i c u l a r patient and h i s drug therapy and he would review the case. Medication Preparation and Administration — Standard drug administration schedules at St. Paul's Hospital vary depending on the s p e c i f i c nursing u n i t . However, i t has been estimated that 90 percent of a l l medications are administered to patients at one or a l l of the established Q.I.D. times(6). Unit dose preparation and d e l i v e r y times would subsequently be established with reference to these major medication administration times i n the h o s p i t a l and the degree of co n t r o l desired by the pharmacy. While the four cabinet exchanges per day system at the University of Kentucky Medical Center(6) i s considered excessive, the two cabinet exchanges per 72 day at the Ohio State University Hospitals(110) and the University of Michigan Medical Center(24) i s f e l t to provide i n s u f f i c i e n t coverage f o r new drug orders between d e l i v e r y times. I t i s therefore recommended that medication carts be delivered to nursing units three times per day. This i s the method presently being used at the University of Wisconsin Hospitals(19). Three times d a i l y , drug d i s t r i b u t i o n technicians would go through a l l patients' "Medication P r o f i l e Worksheets" to determine doses to be prepared for the p a r t i c u l a r time i n t e r v a l . A l l medication cabinets would then be f i l l e d with unit dose packaged drugs f o r a s p e c i f i c length of time. Cart accessories such as alcohol swabs, paper cups, rubber gloves, syringes and needles should be placed i n the carts by the pharmacy technicians. Items such as water, milk, j u i c e should be the r e s p o n s i b i l i t y of nursing personnel. The medication carts would then be checked by a drug d i s t r i b u t i o n pharmacist and released to be transported to the nursing units by the pharmacy technicians. I f a new order i s received i n the pharmacy and the f i r s t dose i s to be administered before the next scheduled delivery time, then one dose should be labeled f or the patient and del i v e r e d by a pharmacy technician to the nursing unit. This drug order would be recorded on the "Medication P r o f i l e Worksheet" and i f further doses are required they would be handled by the usual d i s t r i b u t i o n procedure. Regularly during the day, nursing personnel would review the "Medication Administration Records" to determine which medications are to be given at a s p e c i f i e d time. A f t e r the doses have been given, they would be charted i n the administration records which the nurse would carry with 73 her on the medication cart. I f drug i s not given a "Drugs Not Given Notice" (Appendix V) such as that used at the University of Kentucky Medical Center would be completed by the nurse and placed i n the patient's medication drawer. When the cart i s returned to the pharmacy by the technician, t h i s form would be used to chart doses not given i n the patient's "Medication P r o f i l e Worksheet". "P.R.N." (as circumstances may require) medications should be placed i n a separate section of the patient's medication drawer. I f a drug i s a scheduled "P.R.N." order then a maximum number of doses would be placed i n the drawer to cover the period the cart i s on the nursing un i t . I f the drug i s a non-specific "P.R.N." order, only one dose should be placed i n the drawer. This i s the procedure followed at the Ohio State University Hospitals(110). "P.R.N.s" would be charted i n the "Medication Administration Record" as are regular l y scheduled drugs. "Stat" (immediately) medication orders may be telephoned by a nurse to the pharmacy or brought to the pharmacy by a nursing messenger. The drug d i s t r i b u t i o n pharmacist would immediately enter the drug order information i n t o the non-recurring section of the "Medication P r o f i l e Worksheet" and prepare the dose. The d i r e c t copy of the physician as order should be received i n the pharmacy before the dose i s sent to the nursing u n i t . A f t e r the drug i s given i t would then be charted on the "Medication Administration Record" by the nurse. When a physician discontinues or changes a drug order, the drug d i s t r i b u t i o n pharmacist should enter t h i s date and information i n the 74 "Medication P r o f i l e Worksheet". An automatic stop order p o l i c y should be i n e f f e c t f o r a l l medications except chronic maintenance therapy (e.g. d i g i t a l i s , glycosides, i n s u l i n ) . Approximately twenty-four hours before the l a s t dose i s scheduled, a "Notice of Automatic Stop Order" (Appendix VI) should be f i l l e d out by the pharmacy technician and sent to the nursing unit i n the medication cabinet. This i s the procedure followed at the University of Kentucky Medical C e n t e r ( l l l ) . The nurse would then place t h i s notice i n the patient's chart to bring to the physician's attention. Associated D i s t r i b u t i o n Procedures — In a unit dose d i s t r i b u t i o n system, ward stock items a v a i l a b l e i n bulk to nursing units would be greatly r e s t r i c t e d . The only items to be included as ward stock should be large volume standard intravenous s o l u t i o n s , t o p i c a l d i s i n f e c t a n t s and a n t i -s e p t i c s o l u t i o n s , alcohols, and c e r t a i n ointments, l o t i o n s , and diag-no s t i c items. In addition, each nursing unit would have a supply of drugs to be used i n emergency s i t u a t i o n s . Minimum and maximum le v e l s of each item would be established for the nursing areas at St. Paul's Hospital and automatic replacement of ward stock would be the r e s p o n s i b i l i t y of a pharmacy technician. With reference to the s p e c i a l records and safeguards required, i t i s proposed that n a r c o t i c and c o n t r o l l e d drugs should be dispensed separately from the unit dose d i s t r i b u t i o n system. A form such as that i n use i n the Johns Hopkins H o s p i t a l i s recommended(114). With t h i s method, an accurate control system i s maintained using a twenty-four hour - 75 pharmacy n a r c o t i c d i s p o s i t i o n and nursing audit record (Appendix VII). A pharmacy technician would be responsible f o r obtaining d i s p o s i t i o n records and r e q u i s i t i o n s and f i l l i n g and d i s t r i b u t i n g n a r c o t i c supplies to the nursing s t a t i o n s . A pharmacist would be responsible for checking orders and maintaining inventory records. (d) Unit Dose Preparation S t a f f i n g — Data based on workload or bed capacity f o r p r e d i c t i n g the s t a f f i n g requirements of a c e n t r a l i z e d unit dose preparation area i s l i m i t e d . The drug d i s t r i b u t i o n system at the 365-bed University of Kentucky Medical Center requires one pharmacist and three technicians per s h i f t for process-ing of physicians' orders and the preparation of unit dose cabinets(6). Using t h i s data, i t i s estimated that two pharmacists and four technicians would be needed each s h i f t i n the proposed system at the 621-bed St. Paul's H o s p i t a l . However, since i t i s anticipated the day s h i f t should include two dose preparation periods, approximately f i v e drug d i s t r i b u t i o n tech-nicians would be required during t h i s time with only three technicians needed during the afternoon and evening. Scheduling — Using the cost of drug a l l o c a t i o n s to the nursing units (Table I) as an approximate i n d i c a t o r of drug usage and the bed capacities of these areas, two teams of technicians supervised by one pharmacist each per s h i f t could prepare unit dose medications for the nursing units according to the following scheme: 76 Day S h i f t : Team A — 1 Pharmacist — r 3 Technicians — — 3 r d f l o o r - 5 nursing units 5th f l o o r - 5 nursing units '—6th f l o o r - 2 nursing units (Team.,B — 1 Pharmacist — r 2 Technicians — — 2 n d f l o o r - 4 nursing units — 4 t h f l o o r - 4 nursing units Afternoon S h i f t : Team A 1 Pharmacist — r — 2 Technicians — — 3 r d f l o o r - 5 nursing units 5th f l o o r - 5 nursing units — 6 t h f l o o r - 2 nursing units Team B 1 Pharmacist 1 Technician — 1 -2nd f l o o r - 4 nursing units — 4 t h f l o o r - 4 nursing units A proposed medication cart i d e n t i f i c a t i o n plan f o r St. Paul's H o s p i t a l with the appropriate personnel responsible f o r each medication cart i s given i n Table VII. TABLE VII. PROPOSED CART IDENTIFICATION PLAN AND UNIT DOSE PREPARATION RESPONSIBILITY FOR ST. PAUL'S HOSPITAL3 Floor Nursing Cart Iden- Cart Preparation Cart Check Cart Delivery Unit Service Beds t i f i c a t i o n A.M. ^ P.M. P*M. A.M.v P.M. 2nd 2N Medicine 40 2-1 B . l D.l B D D.l 2E I.C.U. 20 2-2 B . l D . l B D B . l D.l 2SA Medicine 41 2-3 B . l D.L D ^ B D B . l D . l 2SB Medicine 29 2-4 B b A C B . l D.l T o t a l 130 3rd 3M Surgery 32 3-1 A . l C . l A C r A . l : c . l 3N Medicine 32 3-2 A . l C . l A C : A . l C . l 3NN Neurosurgery 23 3-3 A. 3 C.l A C A. 3 C . l 3E Surgery 31 3-4 A . l C . l A C A . l C . l 3S P e d i a t r i c s A c t i v . Unit 49 3-5 Ab C . l B r:C : A . l C . l T o t a l 167 4th 4N E.E.N.T. 35 4-1 B.2 D.l B D ;B.2 D.l 4N Ortho Orthopedics 27 4-2 B.2 D.l B D B.2 D.l 4E Orthopedics 46 4-3 B.2 D.L D B D B.2 D.l 4S Urology 44 4-4 B b A C B.2 D.l T o t a l 152 5th 5M Case Room 4 5-1 A. 2 C.2 A C : A. 2 C.2 5N Gynecology 43 5-2 A. 3 C.2 A C A. 3 C.2 5S Surgery 41 5-3 A. 2 C.2 A C A. 2 C.2 Nursery Nursery 11 5-4 A. 2 C.2 A C A. 2 C.2 5W Renal Unit 7 5-5 A. 3 C.2 A C A. 3 C.2 T o t a l 106 6th 6S Maternity 31 6-1 4 C . l B C A. 2 C . l 6S O.B. Nursery 35 6-2 A b C.2 B C A. 3 : C.2 T o t a l 66 a The pharmacists are referred to as "A", "B", "C", "D". The technicians are indicated by A . l , A.2, A.3, B . l , B.2, C . l , C.2, D . l . b It i s probable that the pharmacists would have some preparation duties, c The morning would include two unit dose preparation periods. 78 Accordingly, proposed unit dose medication cart preparation schedules for these teams are given i n Figure 5 (day s h i f t ) and Figure 6 (afternoon s h i f t ) . I t can be seen from these two Figures that a greater number of technicians would be required during the day s h i f t compared to the afternoon period since the i n t e r v a l between preparation, checking and del i v e r y of each medication cart would be shorter. The drug d i s t r i b u t i o n technicians i n i t i a l l y would f i l l the unit dose cabinets with medications and d e l i v e r them to the appropriate nursing u n i t s . A f t e r these duties had been completed, the technicians would-thennprobably have prepacking, re-stocking and cart maintenance r e s p o n s i b i l i t i e s . The drug d i s t r i b u t i o n pharmacists would be required to check the medication cabinets a f t e r they had been prepared. In some cases they also may have medication preparation duties. During the preparation and de l i v e r y procedure, the pharmacists should, at the same time, receive further medication orders and be responsible f o r updating patients' p r o f i l e s . proposed drug d i s t r i b u t i o n system at St. Paul's Hospital (assuming standard h o s p i t a l Q.I.D. administration times of 9.00 a.m. - 1.00 p.m. - 5.00 p.m. - 9.00 p.m.) would be: Therefore, the basic preparation and d e l i v e r y schedule f o r the CABINET EXCHANGE DELIVERY PERIOD MEDICATION ADMINISTRATION INTERVAL 1 8.30 a.m. - 9.00 a.m. 8.30 a.m. - 11.30 a.m. 2 11.00 a.m. - 11.30 a.m. 11.30 a.m. - 8.30 p.m. 3 6.30 p.m. - 8.30 p.m. 6.30 p.m. - 9.00 a.m. FIGURE 5. UNIT DOSE PREPARATION AND STAFF SCHEDULE FOR DAY SHIFT AT ST. PAUL'S HOSPITAL 3 79 TECHNICIAN PHARM-ACIST TECHNICIAN i PHARMA-CIST : Time-In t e r v a l A l : A2 A3 A : B l B2 B 7.00 - Cart : Cart Cart Cart Cart Cart Cart 7.30 a.m. 3-1 : 5-1 5-2 3-4 2-1 4-1 2-4 7.30 - Cart Cart Cart Check Cart Cart Check 8.00 3-2 5-3 3-3 Carts 2-2 4-2 Carts 8.00 - Cart Cart Cart Check Cart Cart Check 8.30 3-4 5-4 5-5 Carts 2-3 4-3 Carts 8.30 - Del Del Del Check Del Del Check 8.40 3-1 5-1 5-2 Carts : 2-1 4-1 Carts 8.40 - Del Del Del Cart Del Del Cart 8.50 3-2 5-3 3-3 6-1 6-2 2-2 4-2 4-4 8.50 - Del Del Del Check Del Del Check 9.00 a.m. 3-4 3-5 5-4 6-1 5-5 6-2 Carts 2-3 2-4 4-3 4-4 Carts 9.00 -9.30 a.m. UNS'CHEDF LED TIMEt r < 9.30 - Cart Cart Cart Cart Cart Cart Cart 10.00 a.m. 3-1 5-1 5-2 3-5 ' 2-1 4-1 2-4 10.00 - Cart Cart Cart Check Cart Cart Check 10.30 3-^ 2 5-3 3-3 Carts 2-2 4-2 Carts 10.30 - Cart Cart Cart Check : Cart Cart Check 11.00 3-4 5-4 5-5 Carts 2-3 4-3 Carts 11.00 - Del Del Del Check Del Del Check 11.10 3-1 5-1 5-2 Carts 2-1 4-1 Carts 11.10 - Del Del Del Cart Del Del Cart 11.20 3-2 5-3 3-3 6-1 6-2 2-2 4-2 4-4 11.20 - Del Del Del Check Del Del Check 11.30 a.m. 3-4 3-5 5-4 6-1 5-5 6-2 Carts 2-3 2-4 4-3 4-4 Carts 11.30 -12.30 p;.m. UNSCHEDULED TIME 12.30 - Prepackingag Update Prepacking-- Update 1.30 p.m. Cart Maintenance Profiles 3 Cart Maintenance P r o f i l e s 1.30 -~2C00pp?m. UNSCHEDULED TIME 2.00 - Prepackingcg Update Prepackingag Update 3.00 p.m. Cart Maintenance P r o f i l e ! 3 Cart Maintenance P r o f i l e s "Cart", "Check", and "Del" r e f e r , r e s p e c t i v e l y , to the f i l l i n g of unit dose medication carts by technicians, checking of these carts by a pharmacist and d e l i v e r y of the cart to the nursing u n i t s . The number, e.g., 3-1, refers to the cart assigned to nursing unit "1" on the 3rd f l o o r . Unscheduled time refers to meal breaks, coffee breaks, etc. 80 FIGURE 6. UNIT DOSE PREPARATION AND STAFF SCHEDULE FOR AFTER-NOON SHIFT AT ST. PAUL'S HOSPITAL3 TIME PERIOD TECHNICIAN PHARMACIST TECHNICIAN PHARMACIST C.l C.2 C . D.l D 3.00 -3.30 p.m. Cart 3-1 Cart 5-1 Receive Orders Cart 2-1 Receive Orders 3.30 -4.00 p.m. Cart 3-2 Cart 5-2 Check Carts Cart 2-2 Cart 2-4 4.00 -4.30 Cart 3-3 Cart 5-3 Check Carts Cart 2-3 Check Carts 4.30 -5.00 p.m. Cart 3-4 Cart 5-4 Check Carts Cart 4-1 Check Carts UNSCHEDULED 5.30 p.m. TIME b 5.30 -6.00 p.m. Cart 3-5 Cart 5-5 Check Carts Cart 4-2 Check Carts 6.00 -6.30 Cart 6-1 Cart 6-2 Check Carts Cart 4-3 Check Carts 6.30 -6.40 Del 3-1 Del 5-1 Check Carts Del 2-1 2-2 Check Carts 6.40 -6.50 Del 3-2 Del 5-2 Update P r o f i l e s Del 2-3 Check Carts 6.50 -7.00 p.m. Del 3-3 Del 5-3 Update P r o f i l e s Del 2-4 4-1 Cart 4-4 7.00 -8.00 p.m. UNSCHEDULED TI ME 8.00 -8.10 p.m. Del 3-4 Del 5-4 Check Carts Del 4-2 ,. . . . 8.10 -8.20 Del 3-5 Del 5-5 Update Del 4-3 8.20 -8.30 Del 6-1 Del 6-2 P r o f i l e s Del 4-4 Update P r o f i l e s 8.30 -9.30 p.m. Prepacking Cart Maintenance Prepacking Cart Maint. J*3Q0" UNSCHEDULED TIME 10C0Q-11.00 p.m. Prepacking Cart Maintenance Update P r o f i l e s Prepacking Cart Maint. Update P r o f i l e s a "Cart", "Check" and "Del" r e f e r , r e s p e c t i v e l y , to the f i l l i n g of unit dose medication carts by technicians, checking of these carts by a pharmacist and de l i v e r y of the cart to the nursing u n i t s . The number, e.g., 3-1, refer s to the cart assigned to nursing unit "1" on the 3rd f l o o r . Unscheduled time refers to meal breaks, coffee breaks, etc. 81 That i s , medication cabinets would be prepared and delivered to the nursing units according to a staggered schedule. The medications i n one cabinet would be administered during the i n t e r v a l from the time the cart reached the nursing unit u n t i l the next cabinet was exchanged. (e) S t a f f i n g Functions In summary, the job r e s p o n s i b i l i t i e s f o r the personnel involved i n the proposed c e n t r a l i z e d unit dose d i s t r i b u t i o n system at St. Paul's H o s p i t a l should be: Drug D i s t r i b u t i o n Pharmacist - receives and sorts copies of physicians' orders; - i n t e r p r e t s a l l orders and enters medication orders i n t o scheduled and non-scheduled areas of patient's "Medication P r o f i l e Worksheet"; - scans a l l medication orders according to c r i t e r i a f o r fur t h e r drug s u r v e i l l a n c e and n o t i f i e s patient-care area pharmacist i f necessary; - supervises technicians i n prepackaging and i n the preparation of unit dose cabinets; - a s s i s t s i n the preparation of unit dose cabinets; - checks unit dose cabinets before d e l i v e r y ; - responsible f o r extemporaneous compounding and " s t a t " medications; - a s s i s t s i n the education programs that are conducted within the pharmacy department. Drug D i s t r i b u t i o n Technician - prepares unit dose cabinets; - transports and exchanges unit dose cabinets and carts on the nursing u n i t s ; 82 - c a r r i e s physicians' orders from the nursing units to the pharmacy; - responsible f o r unit dose prepackaging, restocking shelves and cart maintenance. (f) Comparative Personnel Requirements An important consideration i n this,, proposed unit dose d i s t r i b u t i o n system i s the comparison of present and future pharmacy and nursing s t a f f requirements. An equitable "trade-off" should occur when the number of ant i c i p a t e d a d d i t i o n a l pharmacy personnel are compared to p o t e n t i a l benefits i n decreased nursing time requirements i n medication-r e l a t e d a c t i v i t i e s . A summary of the savings i n nursing time from several hos p i t a l s a f t e r the implementation of unit dose d i s t r i b u t i o n systems i s given i n Table VIII. The Table also contains the approximate p o t e n t i a l nursing time saving i f these values are extrapolated to the St. Paul's Hospital capacity of 575 beds. Although t h i s Table contains data from a range of hospita l s operating d i f f e r e n t unit dose systems, i t gives an i n d i c a t i o n of the possible nursing time which may be freed at St. Paul's H o s p i t a l as a r e s u l t of the proposed system. I f the t o t a l time saved (86.1 hours/day) were expressed i n terms of personnel, approximately 10.8 nursing s t a f f (based on eight-hour s h i f t s per person) would be released as a r e s u l t of decreased medication a c t i v i t i e s at St. Paul's H o s p i t a l . The discussion of the proposed unit dose d i s t r i b u t i o n system i d e n t i f i e s that s p e c i f i c pharmacy personnel would be required f o r d i s t r i -bution duties only. A summary of the present and proposed s t a f f require-ments and hours of service for St. Paul's H o s p i t a l i s given i n Table IX. 83 TABLE VIII. NURSING TIME SAVING OF VARIOUS HOSPITALS AFTER IMPLEMENT-ATION OF UNIT DOSE AND EXTRAPOLATION TO 575 BEDS. Hosp i t a l Unit dose service Nursing time saved (hrs/ day) Extrapol-ation to 575 beds. References University of Iowa 132 beds 14.5 63.2 L i t 70 St. Joseph's Hospital 80 beds 5.5 39.5 Lit- 115 Kettering Memorial Hos p i t a l 400 beds 35.4 50.8 l i t 44 Buffalo General H o s p i t a l 46-49 patients 4.3 52.1 L i t 30 Sunnyb.rook-c H o s p i t a l 22 beds 7.6 198.5 L i t 74 Temple University Hospital 44-53 patients 9.5a 112.6 Li*- 40 Average 86.1 hr/da} T o t a l Personnel 10.8 per-sons^1 a Average time saving i n medication a c t i v i t i e s from nurses, medication nurses, medical students, aides, o r d e r l i e s , and physicians. b Assuming eight hour s h i f t s per person. 84 TABLE IX. SUMMARY OF COMPARATIVE PERSONNEL REQUIREMENTS FOR PHARMACY DRUG DISTRIBUTION AT ST. PAUL'S HOSPITAL PRESENT PROPOSED k Pharmacists 5 5.6 Technicians 3 a 11.2 Net Reduction i n Nursing Personnel (est.) — 10.8C D a i l y Hours of Service 9.5(or 9)hr 16 hr. a Includes one aide f o r ward stock, one aide f o r manufacturing and restocking and one c l e r i c a l personnel. b Proposed personnel requirements discussed -.under unit dose s t a f f i n g (p. 75) were based on d a i l y needs. To provide weekend coverage these figures have been m u l t i p l i e d by 1.4 c See Table VIII p. 83. 85 It can be seen from t h i s Table that about a 68 percent increase i n hours of active coverage i s proposed. To meet t h i s added service an a d d i t i o n a l 8.8 pharmacy personnel (pharmacists and technicians) would be required. Although t h i s represents a large increase over the current s t a f f , i t must be viewed within the context that a p o t e n t i a l reduction of 10.8 nursing positions may r e s u l t with the implementation of the c e n t r a l i z e d unit dose d i s t r i b u t i o n system. An equitable "trade-o f f " i t appears, may r e s u l t . An important feature of these projected services at St. Paul's H o s p i t a l with reference to s t a f f i n g i s the proposed p r o v i n c i a l Drug and Poison Information Center. In t h i s proposal, h o s p i t a l pharmacy residency candidates (graduate pharmacists) would provide a d d i t i o n a l " o n - c a l l " service to the information center during evening and night hours(104). It i s , therefore, anticipated that t h i s service also would provide back-up " o n - c a l l " service f or drug d i s t r i b u t i o n , i n t r a -venous admixture and drug information systems within the h o s p i t a l . The net r e s u l t of t h i s residency involvement would be to a s s i s t the pharmacy department i n providing twenty-four hours per day, seven days a week service to St. Paul's H o s p i t a l . E. Intravenous (I.V.) Admixture Service Intravenous Admixture Systems Analysis Several approaches have been used to implement successful I.V. admixture programs. A b a s i c consideration i n the development of 86 t h i s service i s the associated medication d i s t r i b u t i o n system. The c e n t r a l i z e d and combination unit dose hospit a l s l i s t e d i n Table V a l l provide a c e n t r a l I.V. admixture preparation service. An analysis of these systems as follows indicates the r e l a t i o n s h i p to drug d i s t r i -bution systems and the d i f f e r e n t approaches which might be used. At the Ohio State University Hospitals, intravenous solutions and admixtures are ordered by nursing personnel using a copy of the physicians' o r i g i n a l order(110). Admixture labels are generated by computer and a twelve hour supply of solutions i s delivered from the c e n t r a l admixture area to the nursing unit(116). At the University of Michigan H o s p i t a l I.V. admixtures are prepared i n the c e n t r a l pharmacy upon the receipt of a personal prescription(117). At the Un i v e r s i t y of F l o r i d a teaching h o s p i t a l , the c e n t r a l pharmacy provides intravenous admixture and hyperalimentation solutions on an 8% hour per day basis(118). In contrast, the experimental decentralized unit dose systems described at the University of Iowa Hospitals(70) and the Johns Hopkins Hospital(27) provide intravenous admixture solutions from the pharmacy substations. In the t o t a l h o s p i t a l unit dose system at the Buffalo General Hospital intravenous admixtures are prepared and dispensed from the six decentralized s a t e l l i t e s ( 3 0 ) . To provide t h i s s e r v i c e , s i x bench model laminar a i r flow hoods were required at a t o t a l cost of $3000. The e s s e n t i a l feature of these programs i s that the nature of the intravenous admixture service i s pre-determined by the medication d i s t r i b u t i o n system. More detailed information s p e c i f i c a l l y related to the - 87 development of an intravenous additive preparation service has been described by Holysko and Ravin(81) and Ravin(119) at the 522-bed St. Joseph Mercy H o s p i t a l , Ann Arbor, Michigan, and by Wenger and Kabat(79) at the 1014-bed Minneapolis Veterans H o s p i t a l . In these programs, intravenous additive solutions are prepared and dispensed from the ce n t r a l pharmacy upon the receipt of a copy of the physician's order or by a telephone order from the nurse. These services are provided on a ten to twenty-four hour per day basis by the pharmacists. Complete intravenous additive preparation and administration programs have been described by Wuest(83,86,120) at the 300-bed St. Francis H o s p i t a l , C i n c i n n a t i , Ohio, and by Pulliam and Upton(84) at the 427-bed Moses H. Cone Memorial H o s p i t a l , Greensboro, North Carolina. In these cases, I.V. therapy nurses under the supervision of the pharmacy depart-ments prepare and administer a l l I.V. solutions with additives and hyperalimentation f l u i d s . The I.V. therapy team i s also responsible f o r taking blood samples from patients f o r cross-matching and the administration of blood and blood products. In addition, they may be required to attend cardiac emergencies to do venepunctures and to prepare medications(84). A summary of s t a f f coverage and workload of several hosp i t a l s with an intravenous admixture service i s given i n Table X. The Table indicates that there may be v a r i a t i o n s i n pharmacy service to the admixture program, I.V. therapy nursing teams involved, and d i f f e r i n g I.V. admixture workloads. The types of programs described by Wuest(120) and Pulliam and Upton(84) would appear to be best suited to a proposed St. Paul's TABLE X. WORKLOAD AND STAFF COVERAGE OF FIVE HOSPITALS WITH PHARMACY INTRAVENOUS ADMIXTURE SERVICE. HOSPITAL HOSPITAL BEDS WORKLOAD OR TOTAL BEDS SERVED 24 HOUR STAFF COVERAGE PHARMACISTS I.V. THERAPY NURSES TECHNICIANS COURIERS,CLERKS? REFERENCE St. Francis Hospital ( C i n c i n n a t i , Ohio) 300 300 beds 4 a (16 hours/day) 11 2 (8 hours/day) 83 Johns Hopkins Hosp=r.e i t a l (Baltimore, Md.) 1250 386 beds 2 10 3 •i82 St. Joseph Mercy Hosp i t a l , (Ann Arbor, Mich.) 522 111 ad-mixtures per day 3 b - - 85 Moses H. Cone Memorial Hospital (Greensboro, N.C.) 427 42.9 ad-mixtures per day 5 C (15 hours/day) 6d - 84 Minneapolis Veterans Hospital (Minneapolis Minn.) 1014 85 beds 2.5e - 2 e 79 Represents t o t a l number of department pharmacists. Does not include three i n t e r n s . Two pharmacists on day s h i f t and one pharmacist thereafter. Four pharmacists on day s h i f t and one pharmacist during evening. Represents t o t a l s t a f f pharmacists. Includes one part-time nurse. Projection for t o t a l h o s p i t a l service (preparation only) f o r 13 hours per day. co CO 89 H o s p i t a l admixture service because they are integrated with the cen t r a l i z e d medication d i s t r i b u t i o n system with respect to communication of the physician's order. They are also very comprehensive i n that they include a wide range of intravenous therapy procedures. Perhaps a more important feature c l o s e l y r e l a t e d to the present I.V. service at St. Paul's H o s p i t a l i s that an additive service of t h i s type permits the pharmacy to exercise c o n t r o l over the preparation of these solutions and, at the same time, u t i l i z e s the resources, personnel and experience of the nursing s t a f f on the I.V. therapy team. A summary of the present and proposed I.V. admixture services at St. Paul's Hospital i s given i n Table XI. Proposed I.V. Admixture Service (a) Basic System A c e n t r a l i z e d intravenous therapy service such as that described by Wuest(83,88,120) or Pulliam and Upton(84) under the d i r e c t supervision of the pharmacy department of St. Paul's H o s p i t a l i s proposed. The pharmacy should receive, prepare, d i s t r i b u t e a l l new I.V. orders, new and r e f i l l I.V. solutions with additives and hyperalimentation f l u i d s . This service would also be responsible f o r r e c o n s t i t u t i n g parenteral medications and preparing c e r t a i n unit dose i n j e c t a b l e products. The I.V. therapy nursing s t a f f would be o n - c a l l f o r r e s t a r t i n g I.V. sol u t i o n s , checking on problems such as i n f i l t r a t i o n , taking blood samples for cross-matching, and the administration of blood and blood products. An I.V. therapy nurse also should attend h o s p i t a l emergency cases to do venepunctures TABLE XI. SUMMARY OF PRESENT AND PROPOSED INTRAVENOUS ADMIXTURE SYSTEMS AT ST. PAUL'S HOSPITAL SERVICE VARIABLE PRESENT PROPOSED System Separate I.V. therapy service to perform venepunctures and prepare hyperalimentation solutions. Pharmacy supervised I.V. s o l u t i o n , admixture, and hyperalimentation pre-paration i n I.V. preparation area. A l l admixtures to be administered by I.V. therapy nurse. S t a f f I n i t i a t i o n of order into system by f l o o r nurse using physician's order form and/or request f o r I.V. therapy nurse. I.V. therapy nurses perform most I.V. s t a r t s and re-s t a r t s , prepare and administer hyperalimentation solutions. Floor nurses reconstitute parenterals and prepare admixtures. I n i t i a t i o n of order i n t o system by pharmacy technician or nurse using d i r e c t copy of physician's order. A l l I.V. therapy orders recorded by pharmacist. A l l I.V. admixture solutions prepared by I.V. therapy nurse. Pharmacy technician; does mass recon-s t i t u t i o n . Hours of Service 24 hours per day, seven days per week. Pharmacy supervision 7.00 a.m.-11.00 p.m. I. V. admixture preparation and admini-s t r a t i o n 24 hours per day. On-call pharmacy resident a v a i l a b l e I I . 00 p.m.-7.00 a.m. seven days per week. 91 and prepare intravenous admixtures. The intravenous admixture service should provide twenty-four hours per day coverage. However, the pharmacy s t a f f for t h i s program would be scheduled on a two s h i f t per day basis s i m i l a r to the proposed unit dose system. Pharmacists could supervise and a s s i s t i n the pre-paration of intravenous admixtures during the day and afternoon periods. The intravenous therapy nurses would prepare and administer I.V. solutions over the e n t i r e twenty-four hour period. Ravin has reported that at one 522-bed h o s p i t a l approximately one-third of admixture orders are required between 9.00 a.m. and 11.00 a.m.(119) and 80 percent of solutions ordered are requested between 8.00 a.m. and 5.00 p.m.(85). Pharmacy supervision should therefore be scheduled according to the workload at these periods during the day. In the proposed system, the term "I.V. Pharmacist" w i l l be used to define the pharmacist who would supervise the preparation of intravenous admixtures. The "I.V. Technician" would be a supportive person responsible f o r the transportation of standard intravenous solutions to the nursing u n i t s , mass r e c o n s t i t u t i o n of i n j e c t a b l e medi-cations and maintaining inventories i n the I.V. preparation area. The term "I.V. Therapy Nurse" w i l l be used to define a registered nurse responsible for the preparation and administration of intravenous so l u t i o n s . (b) F a c i l i t i e s and Budget Considerations A primary objective of an intravenous admixture service i s 92 to provide f o r the c e n t r a l i z e d preparation of intravenous solutions with additives i n a c o n t r o l l e d environment. Therefore, s p e c i a l i z e d equipment and f a c i l i t i e s would be required to provide a "clean a i r " s e t t i n g . Expenditures f o r equipment and materials, as previously d i s -cussed i n the unit dose system, w i l l vary depending on the manufacturer and model selected. However, based on the survey by Ravin(121) the following items with t h e i r approximate costs are considered e s s e n t i a l f o r t h i s proposed service at St. Paul's H o s p i t a l : - laminar a i r flow hoods $1500-2000 each - small r e f r i g e r a t o r (1-2 cu. f t . ) $100-200 - r e c o n s t i t u t i n g apparatus, syringes, valves, tubing $50 - high i n t e n s i t y lamp $50 - pH meter $200 - work counters, desks $300-600 The number and sizes of the laminar a i r flow hoods required are normally dependent upon the volume of admixture solutions to be prepared during any given period of time. Ravin(119) has determined t h e o r e t i c a l l y that two four foot a i r flow hoods should be able to handle approximately 110 admixtures prepared per day at one 522-bed h o s p i t a l . Using t h i s data, two .console model laminar flow hoods and one bench top model are projected to be required at St. Paul's H o s p i t a l . The smaller unit would be used f o r " s t a t " orders and r e c o n s t i t u t i n g i n j e c t a b l e medications. Although not e s s e n t i a l , a separate room i s highly desirable f o r an intravenous admixture preparation area. A clean a i r environment can be more e a s i l y maintained when th i s equipment i s segregated from the 93 noise, t r a f f i c and atmosphere of the main pharmacy area. In addition, a i r conditioning may be required i f the laminar flow units are confined to a small room where the heat cannot be d i s s i p a t e d over a s u f f i c i e n t l y large area(121). (c) D i s t r i b u t i o n Procedure I n i t i a t i o n of the Physician's Order — A flow chart of the proposed intravenous admixture service i s given i n Figure 7. The ordering, i n t e r p r e t a t i o n and monitoring of intravenous s o l u t i o n orders should be integrated with the proposed c e n t r a l i z e d unit dose system. The d i r e c t copy of the physician's order (Appendix I) would be used to i n i t i a t e a l l orders into the medication cycle. This copy could be transported to the c e n t r a l pharmacy by a nursing unit messenger of a pharmacy technician during the unit dose medication d e l i v e r i e s . The drug d i s t r i b u t i o n pharmacist who receives the order would be responsible f o r i n t e r p r e t i n g the order or c l a r i f i c a t i o n , i f necessary, with the physician (Appendix I I I ) . The order would then be entered i n the patient's "Medication P r o f i l e Work-sheet" (Appendix IV) and the patient's therapy scanned by the pharmacist according to the c r i t e r i a established for further drug s u r v e i l l a n c e (p.104). The drug d i s t r i b u t i o n pharmacist would then prepare an "I.V. Therapy Order Card" such as that used at the Moses H. Cone Memorial H o s p i t a l (Appendix VIII) l i s t i n g the following: - patient name - nursing unit - room - type and s i z e of I.V. s o l u t i o n FIGURE 7. PROPOSED I.V. THERAPY ADMIXTURE SERVICE AT ST. PAUL'S HOSPITAL 94 "DRUG INFORMATION COMMUNICATION FORM" COMPLETED IF NECESSARY "PHARMACY DRUG SURVEILLANCE RECORD" INITIATED OR UPDATED MEDICAL CHART IF ORDER REQUIRES CLARIFICATION-TELEPHONE CONTACT MADE BY PHARMACIST NOTIFICATION AND INFORMATION FROM PROFILE GIVEN TO PHARMACIST RESPONSIBLE FOR DRUG SURVEILLANCE ON PATIENT'S UNIT IF STABILITY OR COMPATIBILITY PROBLEM PHYSICIAN I.V. THERAPY NURSE PHYSICIAN'S ORDER FOR: -MEDICATION -TREATMENT -LABORATORY I.V. THERAPY NURSE CHECKS PHYSICIAN'S ORIGINAL ORDER DIRECT COPY OF PHYSICIAN'S ORDER CARRIED FROM NURSING UNIT TO PHARMACY ORDER RECEIVED IN CENTRAL PHARMACY UNIT DOSE PREPARATION AREA BY PHARMACIST PHARMACIST INTERPRETS ORDER AND ENTERS ORDER INFORMATION IN PATIENT "MEDICATION PROFILE WORKSHEET" "MEDICATION MEMORANDUM" COMPLETED AND ATTACHED TO "I.V. THERAPY ORDER CARD" MEDICATION ORDERS INITIALLY SCANNED BY DRUG DISTRIBUTION PHARMACIST ACCORDING TO CRITERIA FOR FURTHER DRUG SURVEILLANCE DRUG DISTRIBUTION PHARMACIST PREPARES "I.V. THERAPY ORDER CARD" "I.V. THERAPY ORDER CARD" RECEIVED BY PHARMACIST OR I.V. THERAPY NURSE IN I.V. PREPARATION AREA IF NO ADDITIVE REQUIRED I.V. THERAPY NURSE PROCEEDS TO NURSING UNIT TO ADMINISTER SOLUTION I.V. ADDITIVE ORDER CHECKED FOR STABILITY AND COMPATIBILITIES AND LABEL TYPED "I.V. THERAPY ORDER CARD' FILED ON SCHEDULE RACK FOR NEXT SOLUTION I.V. ADMIXTURE ORDER PREPARED BY PHARMACIST OR I.V. THERAPY NURSE FINAL CHECK OF ADMIXTURE SOLUTION MADE BY I.V. PHARMACIST SOLUTION ADMINISTERED TO PATIENT BY I.V. THERAPY NURSE SOLUTION CHARTED IN INTAKE-OUTPUT FORM AND/OR "MEDICATION ADMINISTRATION RECORD" FLOOR NURSE ' MONITORS FLOW RATE AND NOTIFIES I.V. PREPARATION AREA IF PROBLEMS DEVELOP I.V. THERAPY NURSE TAKES I.V. ADMIXTURE SOLUTION TO NURSING UNIT 95 - a d d i t i v e s , amounts - time required (flow rate) - prepared by, checked by. Admixture Preparation and Administration — The order card would be sent to the I.V. preparation area where i t would be received by an I.V. therapy nurse or pharmacist. I f no additives are required, an I.V, therapy nurse would proceed to the nursing unit to s t a r t a standard s o l u t i o n . I f additives are needed, the I.V. pharmacist should review the order f o r p o t e n t i a l s t a b i l i t y or compatibility problems and type the required l a b e l s . An I.V. therapy nurse would assemble the add i t i v e s , prepare the so l u t i o n and attach the l a b e l to the b o t t l e . The I.V. pharmacist should then make a f i n a l check of the preparation with reference to c a l c u l a t i o n s , l a b e l i n g , s o l u t i o n c l a r i t y and dating and release the admixture to the I.V. therapy nurse. I f successive solutions are required then the order card would be f i l e d on a twenty-four hour scheduling rack f o r when the next solutions would be needed. The I.V. therapy nurse would take the admixture s o l u t i o n to the nursing u n i t , check the physician's o r i g i n a l order and administer the so l u t i o n to the patient. The s o l u t i o n should then be charted i n the patient's "Medication Administration Record" (Appendix II) and/or intake-output form. The f l o o r nursing s t a f f should be responsible f o r monitoring the flow rate and n o t i f y i n g the I.V. preparation area i f problems develop. A f t e r a twenty-four hour period, new physicians' orders should be required f o r a l l continuing intravenous therapy s o l u t i o n s . I f two or more solutions are to be alternated, then these admixtures could be prepared and delivered about two hours before they are needed by the patient. 96 S i m i l a r l y to the proposed unit dose system, a f l o o r nurse may telephone " s t a t " I.V. therapy orders to the drug d i s t r i b u t i o n pharmacist. However, the d i r e c t copy of the physician's order should be received i n the pharmacy before the s o l u t i o n i s released. As with regular I.V. orders the pharmacist would enter the information i n the patient's "Medication P r o f i l e Worksheet" and complete the "I.V. Therapy Order Card". In the I.V. preparation area, a l a b e l would be typed and the admixture prepared, checked and released to an I.V. therapy nurse to administer to the patient. (d) S t a f f i n g The personnel required to s t a f f the proposed pharmacy super-vised intravenous admixture and administration service at St. Paul's H o s p i t a l w i l l be dependent upon the anticipated workload. It has been shown that the workload f o r t h i s type of service may vary depending on two f a c t o r s . One, the amount of continuous versus intermittent I.V. therapy used i n the hospital(122) and two, the r e l a t i v e proportion of s u r g i c a l and medical patients i n the hospital(79). Intermittent I.V. therapy at St. Paul's H o s p i t a l i s v i a I.V. "push" or through the use of a volumetric I.V. administration set (e.g. Volu-Trole ). S u r g i c a l and intensive care beds represent approximately 26 percent of the t o t a l bed capacity (excluding b a s s i n e t s ) . Wenger and Kabat(79) found that medical patients received 0.134 infusions per patient day, while s u r g i c a l patients averaged 0.423 infusions per patient day on two nursing units i n a 1014-bed h o s p i t a l . Using these f i g u r e s , approximately 110 infusions would be 97 administered d a i l y at St. Paul's H o s p i t a l . Ravin(119) has found that about 111 admixtures per day were required f o r patients i n a 522-bed h o s p i t a l . Approximately 122 admixtures would, probably, be prepared at St. Paul's H o s p i t a l using t h i s data. An estimation of 110 to 120 admixture infusions per day at St. Paul's Hospital i s considered reasonably accurate(123). Further, Sherrin and coworkers(124) determined t h e o r e t i c a l l y a processing time of 21.1 man-hours per day f o r 112 new and r e f i l l ad-mixture orders i n a private community h o s p i t a l . Actual processing time was 20 man-hours per day which required 3.5 persons for the preparation of intravenous admixture s o l u t i o n s . Using the s t a f f requirements of the hospi t a l s operating I.V. preparation and administration teams given i n Table X and extending the bed capacity and workload to that of St. Paul's H o s p i t a l t h i s proposed service might be s t a f f e d according to the following plan: PERSONNEL DAY EVENING NIGHT I.V. Therapy Nurses 7 3 2 I.V. Pharmacist 1 1 -I.V. Technician 1 -This schedule would provide twenty-four hour t o t a l h o s p i t a l coverage f o r the preparation and administration of admixture solutions and r e l a t e d I.V. therapy duties with pharmacy supervision and assistance during the major preparation periods. Although " o n - c a l l " night coverage by a pharmacy resident i s a n t i c i p a t e d . See p. 85. 98 (e) S t a f f i n g Functions In summary, the job r e s p o n s i b i l i t i e s f o r the personnel involved i n the proposed c e n t r a l i z e d intravenous admixture and admin-i s t r a t i o n service at St. Paul's H o s p i t a l should be: Drug D i s t r i b u t i o n Pharmacist (previously r e f e r r e d to on p. 8-1) - receives copy of the physician's orders; - i n t e r p r e t s orders and enters information i n patient's "Medication P r o f i l e Worksheet"; - scans medication and I.V. therapy orders according to c r i t e r i a f o r further drug s u r v e i l l a n c e and, i f necessary, n o t i f i e s patient-care area pharmacist; - prepares "I.V. Therapy Order Card". I.V. Pharmacist - supervises the I.V. preparation area; - receives the "I.V. Therapy Order Cards"; - checks admixture orders f o r compatibility and s t a b i l i t y problems and, i f necessary, n o t i f i e s patient-care area pharmacist; - prepares admixture l a b e l s ; - a s s i s t s i n the preparation of I.V. admixture and hyhypeiralimentationr solutions; - supervises and a s s i s t s i n the preparation of parenteral unit dose medications; - a s s i s t s i n the education programs that are conducted within the pharmacy department. I.V. Therapy Nurse - receives "I.V. Therapy Order Cards"; - prepares, d i s t r i b u t e s and administers a l l I.V. admixture and hyperalimentation s o l u t i o n s ; - checks admixture orders f o r compatibility and s t a b i l i t y problems; - takes blood specimens f o r cross-match and administers blood and blood products; - checks on problems such as i n f i l t r a t i o n and inflammation at the i n f u s i o n s i t e ; - attends h o s p i t a l emergency c a l l s . 99 I.V. Technician - does mass r e c o n s t i t u t i o n of parenteral medications; - maintains inventory of solutions and additives i n the I.V. preparation area; - d i s t r i b u t e s I.V. solutions on ward stock to the nursing u n i t s . (f) Comparative Personnel Requirements As with the proposed unit dose d i s t r i b u t i o n system, an important consideration i n t h i s admixture service w i l l be the present and future pharmacy, I.V. therapy and nursing s t a f f requirements. A summary of the savings i n nursing time i n several h o s p i t a l s a f t e r the implementation of a c e n t r a l i z e d I.V. preparation service i s given i n Table XII. Tl)e Table also contains the approximate p o t e n t i a l nursing time saving i f these values are extended to the St. Paul's H o s p i t a l capacity of 575 beds and estimated workload of 120 admixtures. S i m i l a r l y to the p r o j e c t i o n of savings i n nursing time with the unit dose system, t h i s Table contains h o s p i t a l s whose data and work measurement may have been calculated by d i f f e r i n g c r i t e r i a . However, i t gives an i n d i c a t i o n of the possible nursing time and personnel (approximately 9.2 persons) which may be freed at St. Paul's H o s p i t a l as a r e s u l t of an intravenous admixture preparation service. This proposed admixture service projects s p e c i f i c pharmacy and I.V. therapy personnel who would be required to s t a f f t h i s program. A summary of the present and proposed personnel and hours of service f o r the admixture preparation and administration service at St. Paul's H o s p i t a l i s given i n Table XIII. The Table shows that the projected reduction i n 100 TABLE XII. NURSING TIME SAVING OF THREE HOSPITALS AFTER IMPLEMENTATION OF AN I.V. ADMIXTURE PREPARATION SERVICE AND EXTENSION TO ST. PAUL'S HOSPITAL'S CHARACTERISTICS HOSPITAL WORKLOAD NURSING TIME SAVED EXTENDED TO ST. PAUL'S REFER-ENCE HOSPITAL St. Joseph Mercy 26,290 admix- 4000 2.3 Ho s p i t a l t u r e s 3 man-hours persons c 85 Minneapolis Vet- 22 admixtures 3 f u l l - t i m e 16.4 d rv. 7 erans' H o s p i t a l per day positi o n s persons 79 St. Francis 300 beds 4 - 7 b 9.0 - -L Ho s p i t a l persons persons 86 Average 9.2 persons Reference indicates 47,800 b o t t l e s of solutions were administered over a two-year period. Of these, 55% of the solutions required the aseptic addition of drugs. k Nursing personnel preparation and administration of I.V. solutions. Calculated to 18.3 hours based on St. Paul's Hospital workload of 120 admixtures. Assume eight hour s h i f t s per person. ^ Based on approximate St. Paul's Ho s p i t a l workload of 120 admixtures. 101 TABLE XIII. SUMMARY OF THE COMPARATIVE PERSONNEL REQUIREMENTS FOR THE I.V. ADMIXTURE SERVICE AT ST. PAUL'S HOSPITAL ; PRESENT PROPOSED Pharmacists - 2.8 b I.V. Therapy Nurses 7 a 16.8 b Technician - 1.4b Net reduction i n floorng nursing personnel(est.) - 9.2C D a i l y hours of service 24 hr. 24 hr. Includes the I.V. therapy supervisor. b Proposed personnel requirements discussed under I.V. admixture s t a f f i n g (p.97>) were based on d a i l y needs. To provide weekend coverage these figures have been m u l t i p l i e d by 1.4. C See Table XII p. 100. .102 f l o o r nursing personnel (9.2 persons) due to elimination of admixture preparation duties almost o f f s e t s the proposed increase i n I.V. therapy nursing personnel (9.8 persons). For pharmacy personnel t h i s would be a new service. Therefore, present and future s t a f f l e v e l s are d i f f i c u l t to compare. However, i t i s an t i c i p a t e d that the 3.2 pharmacy personnel (pharm-a c i s t s and technicians) that would be required could be equally balanced with the expected economic savings i n drug usage and patient safety which would accrue from increased pharmacy supervision. F. Drug Surveillance Program Drug Surveillance Systems Analysis A drug s u r v e i l l a n c e or monitoring program i s an attempt to control the u t i l i z a t i o n of medication according to concepts <" of current therapy. This service i s i d e a l l y achieved when integrated with the drug d i s t r i b u t i o n system. The development of the "combination" and decentral-i z e d unit dose systems are s p e c i f i c a l l y designed to meet t h i s objective. Again, an analysis of e x i s t i n g systems presents the a l t e r n a t i v e approaches which might be taken. At the University of Michigan Medical Center(109) the drug order audit and medication p r o f i l e record are necessary components of the comprehensive "Medication Chronicle System". The patient unit pharmacist i s required to compare new drug orders against the patient's drug h i s t o r y taken upon admission, concurrent medications, laboratory tests and d i e t and review the cost and r a t i o n a l e f o r t h i s therapy(24). In addition, the pharmacist compiles drug experience information which i s a p e r i o d i c a l review of drug therapy and c l i n i c a l status. The patient unit pharmacist i n 103 t h i s system, however, s t i l l retains d i s t r i b u t i o n duties since he i n i t i a t e s the communication of physicians' orders and acts as a drug supply source. B e l l and coworkers(97) have described an e f f i c i e n t method of d e l i v e r i n g drug information through a pharmacy consultation program at a 580-bed h o s p i t a l . The basis of t h i s drug usage s u r v e i l l a n c e program i s f i r s t l y , p r o v i s i o n of information concerning a p a r t i c u l a r patient's drug therapy and secondly, p r o v i s i o n of information whether or not i t i s requested. In t h i s program a drug h i s t o r y i s taken by a pharmacist from the patient upon admission and the patient i s followed during h o s p i t a l -i z a t i o n using a "Drug Information Communication Sheet", a "Drug Summary Form", and a "Laboratory Data Summary Form". During t h i s experimental s e r v i c e , f i v e pharmacists were involved i n monitoring medical and s u r g i c a l patients(125). The only c r i t e r i a f o r s u r v e i l l a n c e of a patient was admission to a nursing unit by one of three physicians whose patients were being served by the pharmacy program. The evaluation of the r e s u l t s of t h i s service showed that, " i n general, physicians read, accepted and u t i l i z e d the information provided by pharmacists"(126). It i s f e l t , however, that consideration should be given to the establishment of more s t r i c t c r i t e r i a f o r patient monitoring when developing a drug usage s u r v e i l l a n c e program. The routine evaluation of therapy and laboratory test r e s u l t s i n patients with uncomplicated medical or s u r g i c a l cases y i e l d s to the i n e f f i c i e n t use of pharmacy personnel. Indeed, the re-s u l t s of the study by B e l l and coworkers(126) showed that only about one-quarter of the patients included i n the program benefited from the pharmacists' communications. Patients who received more drugs, underwent a v a r i e t y of 104 laboratory tests and required longer periods of h o s p i t a l i z a t i o n benefited to a greater degree from this information(126). The establishment of s p e c i f i c , yet f l e x i b l e , c r i t e r i a by the pharmacy department and the Pharmacy and Therapeutics Committee with reference to number of drugs, cost of therapy, classes of drugs and unusual incidents should permit an e f f i c i e n t drug usage s u r v e i l l a n c e program to be provided to the t o t a l h o s p i t a l patient population. Proposed Drug Surveillance Program The primary objective of the proposed s u r v e i l l a n c e service would be to provide f o r the immediate and continuing drug therapy needs of the patients of St. Paul's H o s p i t a l . A summary of the present and proposed drug s u r v e i l l a n c e services i n St. Paul's Hospital i s given i n Table XIV. As discussed previously, preliminary scanning of drug, therapy f o r a l l patients should be a function of the ce n t r a l i z e d drug d i s t r i b u t i o n system. The re l a t i o n s h i p of the proposed s u r v e i l l a n c e program to the unit dose d i s t r i -bution system and the I.V. admixture service i s shown i n Figures 4 and 7. This program would i n i t i a t e upon receipt of the direct copy of the physicians' orders i n the pharmacy. The drug d i s t r i b u t i o n pharmacist would i n t e r p r e t the orders and enter t h i s information on the patient's "Medication P r o f i l e Worksheet" (Appendix IV). This pharmacist should then review the complete drug therapy of the patient with reference to the c r i t e r i a established f o r more intensive monitoring. Further s u r v e i l l a n c e may be warranted on the following grounds: 1. Large number of drugs being administered; 2. Cost of drug therapy; 3. The use of expensive a n t i b i o t i c s ; 4. The use of drugs i n which serious frequent adverse TABLE XIV. SUMMARY OF PRESENT AND PROPOSED DRUG SURVEILLANCE PROGRAMS AT ST. PAUL'S HOSPITAL Service Variable Present Proposed System No formal drug surveillance program established. Drug p r o f i l e available to pharmacists on physician's order form. Formal drug s u r v e i l l a n c e program with a l l medication orders r e -viewed with reference to c r i t e r i a established f o r further drug monitoring. S t a f f Pharmacist reviews medication orders i n course of normal dispensing procedure. I n i t i a l s u r v e i l l a n c e of a l l medication and I.V. orders according to established c r i t e r i a . Further continuing monitoring by patient-care area pharmacist i f necessary. Hours of service Regular pharmacy dispensing hours. 8.00 a.m. - 5.30 p.m. (Mon-Fr i . ) 8.00 a.m. - 5.00 p.m. (Sat-Sun.) Surveillance service scheduled from 7.00 a.m. - 11.00 p.m. On-call pharmacy resident a v a i l -able 11.00 p.m. - 7.00 a.m. seven days per week. 106 reactions are known to occur; 5. The administration of unusual doses of a drug; 6. Unusual drug therapy for a p a r t i c u l a r diagnosis; 7. Upon the report of an adverse drug reaction; 8. The use of chemotherapy i n cancer; 9. Patients r e q u i r i n g parenteral hyperalimentation; 10. An i n d i c a t i o n of possible decreased kidney or l i v e r function (from the medical chart). Patient-care area pharmacists would be n o t i f i e d by the drug d i s t r i b u t i o n pharmacist of the s p e c i f i c patient and would have the respon-s i b i l i t y of continuing the monitoring on the nursing unit. A "Pharmacy Drug Surveillance Form" such as the "Pharmaceutical Service Record (Appendix IX) i n use at the Memorial H o s p i t a l of Long Beach i s recommended as a t o o l to consolidate information for the pharmacist from the patient's medical chart. Using t h i s document the patient-care pharmacist should be able to monitor information such as drug s e l e c t i o n , diagnosis, s u r g i c a l procedures, laboratory tests and progress. I f a s p e c i f i c problem or p o t e n t i a l problem i s i d e n t i f i e d then the pharmacist would present t h i s information to the physician v e r b a l l y or by a "Drug Information Communication Form" such as the "Pharmacy Sheet" (Appendix X) currently a v a i l a b l e at St. Paul's Ho s p i t a l . This type of form permits the physician to reply to the pharmacist's comments. This discussion of the proposed drug s u r v e i l l a n c e program i s b r i e f since the f u l l extent of the service would depend on factors such as the c r i t e r i a (p.10'4) selected for drug monitoring and the experience and effectiveness of the pharmacists i n the patient-care areas. In addition to the drug usage s u r v e i l l a n c e s e r v i c e , two associated programs are proposed to be provided at St. Paul's Hospital by 107 the patient-care area pharmacists. F i r s t l y , a formal adverse drug reaction reporting system should be established. These pharmacists would be responsible f o r i n v e s t i g a t i n g and reporting the circumstances of a suspected adverse drug reaction upon n o t i f i c a t i o n by medical or nursing personnel. The drug therapy of patients receiving more intensive s u r v e i l l a n c e also should be c l o s e l y evaluated for p o t e n t i a l drug reactions. Appropriate s t a t i s t i c s should be maintained of actual drug reaction cases. Secondly, i t i s recommended that drug h i s t o r i e s be taken of selected patients upon admission to the h o s p i t a l . For example, i t may be of value to know a h i s t o r y of previous drug usage i n patients who w i l l be receiving anesthetics i n the h o s p i t a l . Therefore, i f s u r g i c a l patients were selected, i t i s estimated that an average of ten or eleven i n t e r -views would have to be conducted per day f o r patients being admitted to one of the major s u r g i c a l nursing units i n St. Paul's H o s p i t a l ( i . e . , 3M, 3E, 3NN, 5S). (a) S t a f f i n g and F a c i l i t i e s The s t a f f required f o r the duties i n the patient-care areas w i l l l i k e l y depend on the s t r i c t n e s s of the c r i t e r i a established f o r drug s u r v e i l l a n c e . I t was projected by Bohl and coworkers(24) that one pharmacist could be assigned 100 to 125 patients i n the d i s t r i b u t i o n and information system at the University of Michigan Medical Center. In the pharmacy consultation program described by B e l l and coworkers(125) between 130 and 150 patients were a c t i v e l y monitored at any given time by the f i v e pharmacists. However, as previously i n d i c a t e d , these patients represented 108 the inpatient admissions of several physicians. No other c r i t e r i a were established for surveillance(125). Since only about one-quarter of the patients monitored benefited from the pharmacist's information(126), i t i s estimated that four pharmacists could provide drug usage su r v e i l l a n c e and information at St. Paul's H o s p i t a l i f more r i g i d c r i t e r i a were established. That i s , f ewerppharmadisfesrwouM^be-requirediif tfehey-iwere u t i l i z e d e f f i c i e n t l y i n s u r v e i l l a n c e of patients whose drug therapy indi c a t e d that p o t e n t i a l problems may a r i s e . This s t a f f p r o j e c t i o n has also considered the comparable capacities of the 580-bed Mercy H o s p i t a l , Pittsburgh, and the 575-bed St. Paul's H o s p i t a l . Each of these four pharmacists could be assigned one of the four main patient-care f l o o r s i n the h o s p i t a l to handle the drug information requests of the nursing units on that f l o o r . Further, i t i s recommended that two of the four patient-care pharmacists be scheduled on the day s h i f t and the other two scheduled on the afternoon and evening s h i f t to extend this s u r v e i l l a n c e and information service over a greater period of time. It i s not anticipated that this program f o r the h o s p i t a l w i l l require s u b s t a n t i a l expenditures f o r equipment or f a c i l i t i e s . Items such as f i l i n g cabinets, shelves and a desk are highly d e s i r a b l e . In addition, the information needs of t h i s service require basic reference texts and journals covering biopharmaceutics, pharmacology, c l i n i c a l and h o s p i t a l pharmacy, and therapeutics. With reference to the information sources of the pharmacy department i t i s a n t i c i p a t e d that they w i l l be augmented by the proposed p r o v i n c i a l Drug and Poison Information Center(104) at St. Paul's H o s p i t a l . <. 109 (b) Staffing Functions The job responsibilities, in summary, for a patient-care pharmacist involved in the proposed decentralized drug surveillance program at St. Paul's Hospital would be: - to receive notification from the drug distribution pharmacist of patients requiring further drug monitoring; - to receive notification from the I.V. pharmacist of orders which may have compatibility or st a b i l i t y problems; - to review the medical charts of the patient and abstract the required data in a "Pharmacy Drug Surveillance Record"; - to survey appropriate reference sources to obtain required information to assist in making recommendations on the drug therapy of the patient and, i f necessary, complete a "Drug Information Communication Form" and place-: i t in the medical chart; - to investigate and maintain records of adverse drug reaction cases; - to conduct admission drug histories on selected patients; - to receive and handle drug information requests from the medical and nursing personnel; - to assist in the education programs that are conducted in the pharmacy department. c n a pr.arEC'.; (c) Comparative Staff Requirements It is d i f f i c u l t to analyze the present and future personnel needs in this area because this would be, essentially, a new service. The required 5.6 pharmacists would be additions to the present staff. However, the proposed contribution by the hospital pharmacy residency candidates in "on-call" evening and weekend information service(lOA) may * Daily requirement of four pharmacists multiplied by 1.4 for weekend coverage. 110 p o t e n t i a l l y reduce the number of a d d i t i o n a l pharmacists who have been projected. Furthermore, the cost of t h i s s t a f f should be evaluated i n terms of the economic benefits which are expected from decreased medication e r r o r s , reduction i n time spent by nursing personnel f o r t h e i r drug information needs, reduced expenditures due to i r r a t i o n a l or inappropriate drug s e l e c t i o n and increased patient safety from greater p a r t i c i p a t i o n by pharmacy personnel i n the patient-care environment. G. Phasing A f e a s i b l e phasing plan f o r the proposed unit dose d i s t r i b u t i o n , intravenous admixture preparation and drug s u r v e i l l a n c e services at St. Paul's H o s p i t a l i s d i f f i c u l t to project since many i n t e r r e l a t e d factors have to be considered. The discussion of these services has indic a t e d some procedures whose implementation r e l i e s on the success of the development of re l a t e d procedures. In a few cases, however, the program may be implemented independent of other services. This phasing plan w i l l not suggest a time schedule f o r modifications i n ser v i c e s , procedures and p r i o r i t i e s of the present pharmacy department at St. Paul's H o s p i t a l which have been b r i e f l y mentioned i n the Results and Discussion. These include areas such as: developing a complete drug formulary f o r the h o s p i t a l ; r e s t r i c t i n g ward stock s e l e c t i o n and quantities to the nursing un i t s ; p r o v i s i o n f o r automatic replacement by the pharmacy of these ward stocks; modifications to n a r c o t i c and co n t r o l l e d drug d i s t r i b u t i o n ; present services to the out-patient department, d i s -charged patients and h o s p i t a l s t a f f ; and greater p a r t i c i p a t i o n by supportive I l l personnel i n the dispensing process. I t i s f e l t that consideration should be given to these p o l i c i e s and procedures before the implementation of the proposed services i s attempted. It i s important to note that t h i s projected phasing schedule does not preclude the need f o r complete discussions, support and approval of the medical s t a f f , nursing personnel, Pharmacy and Therapeutics Committee and any other group who may be d i r e c t l y involved with these proposed pharmacy services at St. Paul's H o s p i t a l . A basic plan which could be followed f o r the phasing operation of each service i s : 1. S p e c i f i c a t i o n of the service to be provided; 2. A t r i a l study of the service on one or two nursing u n i t s ; 3. Gradual extention of the service throughout the t o t a l h o s p i t a l ; 4. An increase i n the hours of coverage from a one s h i f t to a two s h i f t basis f or t h i s s ervice. This phasing plan presupposes that the required equipment and f a c i l i t i e s f o r the s p e c i f i c service would be a v a i l a b l e at the time they would be required. The projected s t a f f l e v e l s should be gradually attained i n a manner commensurate with the pharmacy service workload and hours of coverage. Drug D i s t r i b u t i o n Several stages probably would be necessary during the implementation of the proposed c e n t r a l i z e d unit dose system. I n i t i a l l y , an extensive prepackaging operation should be i n s t i t u t e d to speed present dispensing procedures. Since the pharmacy currently receives a d i r e c t 112 copy of the physicians' orders, the development of complete patient p r o f i l e s should be attempted. High accuracy must be obtained i n these records before the unit dose system can be commenced. Secondly, through these p r o f i l e s i t may then be possible to supervise a "stop order" p o l i c y with the r e s p o n s i b i l i t y f o r "Notice of Automatic Stop Order" being given to the pharmacy rather than delegated to nursing personnel. The patient p r o f i l e s also would permit the pharmacy to project the date when the department could automatically replace depleted stocks of dispensed medications without nursing r e f i l l r e q u i s i t i o n s . A stage i n which medications are dispensed i n in c r e a s i n g l y r e s t r i c t e d quantities should be attempted before the actual unit dose system i s implemented. For example, rather than the present s i x day supply, medications could be dispensed i n three or four day quantities which may subsequently be followed by one or two day supplies. This procedure could give the pharmacy department an i n d i c a t i o n ofworkload that could be expected i n a ce n t r a l i z e d unit dose d i s t r i b u t i o n system. The f i n a l phase would then be the actual d i s t r i b u t i o n of prescribed medications i n s i n g l e unit packages u t i l i z i n g the three per day medication cabinet exchange procedure. Intravenous Admixture Preparation Since an intravenous therapy nursing team i s presently established at St. Paul's H o s p i t a l , t h i s service should not be too d i f f i c u l t to implement. The pharmacy department, i n i t i a l l y , should attempt to maintain accurate intravenous f l u i d therapy p r o f i l e s using the d i r e c t copy of the physicians' orders. Secondly, the present I.V. therapy team 113 should gradually assume r e s p o n s i b i l i t y for the preparation of a l l admixture solutions administered i n the h o s p i t a l using the current ordering procedure. In th i s stage, the pharmacy department should become more a c t i v e l y involved i n the preparation of these pharmaceut-i c a l s . F i n a l l y , the c e n t r a l i z e d intravenous admixture service could be implemented using the d i r e c t copy of the physicians' orders for the preparation of the "I.V. Therapy Order Cards". In addition, t h i s service would be responsible f o r the preparation and r e c o n s t i t u t i o n of i n j e c t a b l e unit dose medications when the unit dose d i s t r i b u t i o n system i s imple-mented. Drug Surveillance Program The drug usage s u r v e i l l a n c e program should be able to be implemented reasonably independent of the other proposed se r v i c e s . Again, the patient drug p r o f i l e s which have been previously described would be used to i n i t i a t e the program. As indicated i n the basic plan for phasing (p. I l l ) the p r o f i l e s should be maintained, f i r s t l y , on patients of one or two nursing u n i t s . This would allow the pharmacy department to develop competence and accuracy i n these records. Concurrently, s p e c i f i c c r i t e r i a f o r more intensive monitoring of drug therapy should be established. As thi s program develops, these c r i t e r i a may be broadened to permit drug usage su r v e i l l a n c e of a greater number of patients. F i n a l l y , the two a d d i t i o n a l services — patient drug h i s t o r y interviews and the adverse drug reaction reporting program — could be i n i t i a t e d . A c t u a l l y , since they are not dependent on any other services they could be implemented at any time along t h i s phasing schedule. L,114 Suggested Schedule For the purposes of i l l u s t r a t i o n , a two-year phasing schedule w i l l be projected. Therefore, a summary of a possible phasing plan i n d i c a t i n g the. i n t e r r e l a t i o n s h i p s i n the development of the proposed centra l i z e d unit dose d i s t r i b u t i o n , intravenous admixture preparation and drug s u r v e i l l a n c e systems at St. Paul's Hospital i s given i n Figure 8. FIGURE 8. POTENTIAL PHASING SCHEDULE FOR THE PROPOSED PHARMACY SERVICES AT ST. PAUL'S HOSPITAL PROPOSED SERVICE I M P L E M E N T A T I O N YEAR 1 YEAR 2 UNIT DOSE DISTRIBUTION SYSTEM Prepackaging Operation Patient Drug P r o f i l e s | Supervision of Stop Order P o l i c y Automatic P r e s c r i p t i o n Replacement Dispensing of R e s t r i c t e d Quantities  Cent.Unit Dose System INTRAVENOUS ADMIXTURE PREPARATION SERVICE Intravenous F l u i d Therapy Patients P r o f i l e s I.V. Therapy Team to Prepare a l l Admixtures I Pharmacy Supervision of Admixture Preparation Cent. Admixture Service Unit Dose Injectables DRUG SURVEILLANCE PROGRAM Patient Drug P r o f i l e s Surveillance crj-teria Continuing Evaluation of C r i t e r i a Drug Usage Monitoring i n Patient-care Areas Adverse Drug Reaction Reporting Program Patient Drug Interviews 116 SUMMARY The t r a d i t i o n a l or conventional method of drug d i s t r i b u t i o n within h o s p i t a l s has been i d e n t i f i e d as a system over which the pharmacist has very l i t t l e c o n t r o l . The c h a r a c t e r i s t i c s of t h i s system which have resulted from the pharma-c i s t ' s minimal input to drug d i s t r i b u t i o n and drug use control include: the frequent occurrence of medication e r r o r s ; the large amount of time required by nursing personnel to perform medication-related a c t i v i t i e s ; s u b s t a n t i a l drug inventories l o s t through "shrinkage"; the preparation of intravenous admixtures i n areas not conducive to aseptic compounding; the occurrence of predictable adverse drug reactions; and the hazards and high cost of inappropriate drug s e l e c t i o n . These l i m i t a t i o n s , s i n g l y and i n combination, have been demonstrated to be responsible f o r greatly increasing health care costs as a r e s u l t of prolonging patient stay i n h o s p i t a l s . The features of the unit dose d i s t r i b u t i o n system make i t possible f o r the pharmacy department to exercise a greater c o n t r o l l i n g influence over the use of medications i n h o s p i t a l s and, consequently, reduce the above problems. This system, integrated with progressive h o s p i t a l trends such as a pharmacy-supervised intravenous admixture preparation service and an active drug use s u r v e i l l a n c e program also has been shown to a s s i s t the pharmacy department i n contributing to an improvement i n patient care r e l a t e d to drug therapy. The present study showed that the e x i s t i n g drug d i s t r i b u t i o n system at St. Paul's Hospital possesses some of the i d e n t i f i e d d e f i c i e n c i e s . However, u t i l i z i n g information obtained from the l i t e r a t u r e , several proposed modifications to the present pharmacy services could be implemented to c l o s e l y approximate the above progressive trends. The proposed services that have been recommended at St. Paul's Hospital are: 117 1. A c e n t r a l i z e d unit dose d i s t r i b u t i o n system. In t h i s system, most medications would be prepared by pharmacy technicians under the super-v i s i o n of a pharmacist. Medications would be delivered to nursing units on a three cabinet exchange per day b a s i s ; 2. A c e n t r a l i z e d intravenous admixture preparation and administration se r v i c e . This service would u t i l i z e the present I.V. therapy team at St. Paul's H o s p i t a l to prepare and administer a l l I.V. admixtures ordered i n the h o s p i t a l . The pharmacy department would have super-v i s o r y r e s p o n s i b i l i t i e s ; 3. A drug usage s u r v e i l l a n c e program. This s e r v i c e , integrated with the unit dose d i s t r i b u t i o n system, would u t i l i z e patient drug p r o f i l e s to i d e n t i f y p o t e n t i a l drug-related problems. C r i t e r i a would be estab-l i s h e d to indicate patients who may require more de t a i l e d drug monitoring by pharmacists i n the patient-care areas. The information obtained from l i t e r a t u r e sources also projected the a n t i c i p a t e d equipment and f a c i l i t i e s necessary for the proposed services. In ad d i t i o n , t h i s study used a v a i l a b l e data from other r e l a t e d programs to project future personnel requirements to implement the services. Approximately a 68 percent increase over present hours of pharmacy coverage i s proposed (from 9.5 to 16 hours per day). In addition, new pharmacy involvement also over extended hours of coverage i n intravenous admixture prepara-t i o n and drug usage s u r v e i l l a n c e i s projected. The e f f e c t of the above new and extended services on the number of pharmacy and nursing personnel i s summarized i n Table XV. The table i l l u s t r a t e s s everal features. F i r s t l y , very l i t t l e increase i n the number of pharmacists i s projected to s t a f f the unit dose d i s t r i b u -t i o n system. The larger s t a f f i n t h i s area would be p r i m a r i l y due to supportive personnel (technicians). Secondly, when a comparison i s made between the'.'.existing drug d i s t r i b u t i o n system extrapolated to 16 hours per day and the proposed unit dose system a very small difference i n personnel i s estimated. This indicates that TABLE XV. SUMMARY OF PROJECTED COMPARATIVE PERSONNEL REQUIREMENTS AS A RESULT OF PROPOSED PHARMACY SERVICES AT ST. PAUL'S HOSPITAL. A. UNIT DOSE DRUG DISTRIBUTION ' PERSONNEL NUMBER OF PERSONNEL PRESENT SYSTEM PROPOSED SYSTEM DIFFERENCE DIFFERENCE IN PROJECTED CHANGE (19.5 HOURS OF (16 HOURS OF COV- IN PHARMACY FLOOR NURSING IN TOTAL SERVICE PER DAY) ERAGE PER DAY) PERSONNEL PERSONNEL PERSONNEL PHARMACISTS 5 ( 1 0 ) a 5.6 + 0.6 TECHNICIANS 3 (6)* 11.2 + 8.2 SUBTOTAL 8 ( 1 6 ) a 16.8 + 8.8 - 10.8 b - 2.0 B. I.V. ADMIXTURE PREPARATION SERVICE PERSONNEL NUMBER OF PERSONNEL PRESENT SYSTEM PROPOSED 24 HOUR SYSTEM DIFFERENCE DIFFERENCE IN PROJECTED (24 HOURS OF (16 HOURS OF PHARMACY IN PHARMACY FLOOR NURSING CHANGE IN TO-SERVICE PER DAY) COVERAGE PER DAY) PERSONNEL ^PERSONNEL TAL PERSONNEL PHARMACISTS 0 2.8 + 2.8 TECHNICIANS 0 1.4 + 1.4 I.V. THERAPY 16.8 1 + 9.8 NURSES 7 SUBTOTAL 7 21.0 + 14.0 - 9.2 C 4- 4.8 C. DRUG SURVEILLANCE PROGRAM PERSONNEL NUMBER ' OF PERSONNEL PRESENT SYSTEM PROPOSED SYSTEM (16 HOURS OF COVERAGE PER DAY) DIFFERENCE IN PHARMACY PERSONNEL DIFFERENCE IN FLOOR NURSING PERSONNEL PROJECTED CHANGE IN TOTAL PERSONNEL PHARMACISTS 0 5.6 + 5.6 SUBTOTAL 0 5.6 + 5.6 + 5.6 TOTAL 15 43.4 28.4 - 20.0 + 8.4 a Present system projected to 16 hour coverage considering present f u l l s t a f f pattern of one s h i f t as 8 hours. b From Tabi£ VIII, p. 83. c From Table XII, p. 100. 119 the a d d i t i o n a l personnel required f o r the proposed system would probably be due to extended hours of service and not s p e c i f i c a l l y to the unit dose system i t s e l f . T h i r d l y , although the projected personnel requirements f o r the I.V. admixture pre-paration service and the drug s u r v e i l l a n c e program appear s u b s t a n t i a l they must be considered as new or modified services f o r the pharmacists and I.V. therapy nurses. Therefore, i t i s d i f f i c u l t to make accurate comparisons i n these areas between e x i s t i n g and proposed programs. In addition, the pharmacy department would assume r e s p o n s i b i l i t y f o r d e l i v e r i n g a l l drug items thus r e l i e v i n g t h i s duty from the h o s p i t a l messenger and transportation services. In summary, the 28.4 personnel difference between e x i s t i n g and proposed pharmacy s t a f f s would be due to a combination of increased hours of service and greater pharmacy r e s p o n s i b i l i t i e s . This study has estimated that a p o t e n t i a l reduction of about twenty f l o o r nursing personnel may be possible as a r e s u l t of increased pharmacy respon-s i b i l i t i e s . I t should be recognized that t h i s f i g u r e i s for i l l u s t r a t i v e and com-parative purposes only. This quantity has been projected from time r e s u l t s of other studies and does not n e c e s s a r i l y i n d i c a t e that a t o t a l of twenty i n d i v i d u a l nursing positions w i l l be released or freed. Many people previously involved i n the drug d i s t r i b u t i o n cycle such as registered nurses, student nurses, p r a c t i c a l nurses, nurse aides, physicians and medical students w i l l spend le s s time i n medi-catio n - r e l a t e d a c t i v i t i e s when the pharmacy assumes more r e s p o n s i b i l i t y i n t h i s area. However, considering t h i s reduction i n f l o o r nursing personnel as i n d i v i d u a l p o s i t i o n s , a t o t a l net increase of only 8.4 persons or approximately 55 percent over present s t a f f i n g l e v e l s are projected to be required at St. Paul's Hospital. 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Hynniman, C.E., "A Comparison of Costs Associated with the Unit Dose and T r a d i t i o n a l Drug D i s t r i b u t i o n Systems", Paper presented at the Second Nationwide Seminar on Unit Packaging f o r Pharma-c e u t i c a l s , St. Louis, Mo., May 18-20, 1970. 64. Schnell, B.R., Can. J . Hosp. Pharm., XXVI, 22 (1973). 65. S l a t e r , W.C, Jacobsen, R. , Hripko, J.R. and Schmid, M.E., Hospitals, 46, 88 ( A p r i l 16, 1972). 66. H i l l , W.T., B l a i r , W.T. and M i t c h e l l , N.M., Hospitals, 44, 96 (March 16, 1970). 67. Schnell, B.R. and Hammel, R.W., Can. J . Hosp. Pharm., XXIV, 123 (1971). 68. U.S. General Accounting O f f i c e , Study of Health F a c i l i t i e s C o n s t r u c -t i o n Costs, "Unit Dose: L i f e - c y c l e Cost Analysis and Application to a Recently Constructed Health Care F a c i l i t y " , i n "Unit Dose Drug D i s t r i b u t i o n Systems", American Society of Ho s p i t a l Pharmacists, Washington, D.C, 1972, pp. 219-244. 69. Hynniman, C E . , Conrad, W.F., Urch, W.A. , Rudnick, B.R. , and Parker, P.F., "A Comparison of the University of Kentucky Unit Dose System with T r a d i t i o n a l Drug D i s t r i b u t i o n Systems", Paper presented to the Fourth Annual Midyear C l i n i c a l Meeting of the American Society of Hospital Pharmacists, Washington, D.C, Dec. 16, 1969. 70. Black, H.J. and Tester, W.W., Am. J . Hosp. Pharm., 24, 120 (1967). 71. Atherton, G., "A F e a s i b i l i t y Study of Unit Dose Drug D i s t r i b u t i o n i n The Banfield P a v i l i o n of The Vancouver General H o s p i t a l " , unpublished report submitted i n p a r t i a l f u l f i l m e n t of the require-ments of Pharmacy Residency Program, Vancouver, B.C., Canada, 1973. 72. O'Toole, A.E., "A Study of a Unit-dose D i s t r i b u t i o n System i n a Chronic Care Treatment Section on a Eight-hour Basis", unpublished report, H a l i f a x , N.S., Canada, 1972. 73. Keams, G. , "Costs of 24 Hour Unit Dose Service", unpublished report, H a l i f a x , N.S., Canada, 1973. 74. Canada, A.T. and Stewart, D.J., Hosp. Admin. Can., 15, 70 (1973). 1 2 5 7 5 . Task Force on the Cost of Health Services i n Canada, Vol. 2 , Queen's P r i n t e r f o r Canada, Ottawa, Ont., 1 9 7 0 , pp. 1 2 4 - 1 2 5 . 7 6 . Canadian Society of H o s p i t a l Pharmacists, "A Proposal to Study Unit-dose Drug D i s t r i b u t i o n i n Canadian Hospitals", unpublished report, Toronto, Ont., 1 9 7 1 . 7 7 . Anon., Can. J . Hosp. Pharm., XXVI, 1 2 ( 1 9 7 3 ) . 7 8 . A l l i s o n , E., Hosp. Pharm., _1» 3 0 ( M aY 1 9 6 6 ) . 7 9 . Wenger, J.C. and Kabat, H.F., Drug. I n t e l l . , J L , 2 5 4 ( 1 9 6 7 ) . 8 0 . Thur, M.P., M i l l e r , W.A. and L a t i o l a i s , C.J., Am. J . Hosp. Pharm., 2 9 , 2 9 8 ( 1 9 7 2 ) . 8 1 . Holysko, Sr. M.N. and Ravin, R.L., Am. J. Hosp. Pharm., 2 2 , 2 6 7 ( 1 9 6 5 ) . 8 2 . Schwarz, M.A., B u l l . Parentr. Drug. Assoc., 2 3 , 7 8 ( 1 9 6 9 ) . 8 3 . Wuest, J.R. , Drug I n t e l l . C l i n . Pharm., 4_, 1 5 3 ( 1 9 7 0 ) . 8 4 . Pulliam, C.C. and Upton, J.H., Am. J . Hosp. Pharm., 2 8 , 9 2 ( 1 9 7 1 ) . 8 5 . Ravin, R.L., G i l b e r t , J.R. and Comiskey, J.A., Hospitals, 4 1 , 8 8 (Jan. 1 6 , 1 9 6 7 ) . 8 6 . Wuest, J.R., Drug I n t e l l . C l i n . Pharm., _4, 1 2 5 ( 1 9 7 0 ) . 8 7 . Melmon, K.L., New Eng. J . Med., 2 8 4 , 1 3 6 1 ( 1 9 7 1 ) . 8 8 . S e i d l , L.G., Thornton, G.F., Smith, J.W. and C l u f f , L.E., B u l l . Johns Hopkins Hosp., 1 1 9 , 2 9 9 ( 1 9 6 6 ) . 8 9 . Hoddinott, B.C., Gowdey, C.W., Coulter, W.K. and Parker, J.M., Can. Med. Assoc. J . , £ 7 , 1 0 0 1 ( 1 9 6 7 ) . 9 0 . Schimmel, E.M. , Ann. Intern, Med., 6 0 , 1 0 0 ( 1 9 6 4 ) . 9 1 . O g i l v i e , R.I. and Ruedy, J . , Can. Med. Assoc. J . , 9 7 ^ 1 4 5 0 ( 1 9 6 7 ) . 9 2 . Hurwitz, N., Br. Med. J . , 1, 5 3 9 ( 1 9 6 9 ) . 9 3 . U.S. Department of Health, Education and Welfare Task Force on Pr e s c r i p t i o n Drugs: F i n a l Report, U.S. Government P r i n t i n g O f f i c e , Washington, D.C., 1 9 6 9 . 126 94. Borda, I.T., Slone, D. and J i c k , H., J.A.M.A., 205, 645 (1968). 95. Roberts, A.W. and V l s c o n t i , J.A. , Am. J . Hosp. Pharm., 29_> 828 (1972). 96. Vance, P., "The E f f e c t of a Pharmacist Drug Surveillance Program i n an Acute Care Ward", unpublished report submitted i n p a r t i a l f u l f i l m e n t of the requirements of Pharmacy Residency Program, North Vancouver, B.C., Canada, 1972. 97. B e l l , J.E., Grimes, B.J., Bouchard, V.E. and Duffy, Sr. M.G., Am. J . Hosp. Pharm., 27_> 2 9 (1970). 98. Pearson, R.E., S a l t e r , F.J., Bohl, J.C., Thudium, V.F. and P h i l l i p s , G.L., Am. J . Hosp. Pharm., 27, 911 (1970). 99. Anderson, R.D. and L a t i o l a i s , C.J., Am. J . Hosp. Pharm., 22, 53 (1965). 100. Burkholder, D., Am. J . Hosp. Pharm., 22, 48 (1965). 101. Smith, Wi'E., Drug I n t e l l . C l i n . Pharm., 4>, 73 (1970). 102. Bouchard, V.E., " C l i n i c a l Pharmacy Roles of the Pharmacist i n Behalf of the Horizontal Patient", i n the "Expanded Role of the Pharmacist i n Government Health Services" proceedings i n C l i n i c a l P r a c t i c e , A i r l i e House, Warrenton, V i r g i n i a , May 24-26, 1972, p.30. 103. Yakimets, E., "Pharmacy Drug Surveillance Project U t i l i z i n g Nurses' Kardex at Vancouver General H o s p i t a l " , unpublished report, Vancouver, B.C., Canada, 1973. 104. Hlynka, J.N. , " P r o v i n c i a l Drug and Poison Information Center. A Proposal to Develop a P r o v i n c i a l Drug and Poison Information Service System Throughout B.C. Hospitals and Health Centres by E s t a b l i s h i n g a 24 Hour Resource Information Centre Based at St. Paul's H o s p i t a l " , unpublished report, Vancouver, B.C., Canada, 1973. 105. Dosdall, C., D i r e c t o r of Planning and Construction, St. Paul's H o s p i t a l , personal communication, 1973. 106. "Medical S t a f f Rules and Regulations", St. Paul's H o s p i t a l , Section XIII, Rules and Regulations of the Pharmacy Department, p. 42. 107. H o s p i t a l Systems Study Group, Report I I , "A Computer-assisted Decentralized Unit-dose Drug D i s t r i b u t i o n System", Uni v e r s i t y H o s p i t a l , University of Saskatchewan, Saskatoon, 1969. 127 108. Brodie, D.C, personal communication to Dr. F. Morrison regarding the 9th Floor pharmacy project at the H.C M o f f i t t H o s p i t a l , University of C a l i f o r n i a , San Francisco, C a l i f . , 1967. 109. McLean, W.M., Bohl, J.C., Scott, W.V., Meyer, F., Thudium, V.F. and P h i l l i p s , G.L., Am. J . Hosp. Pharm., 26, 399 (1969). 110. The Ohio State University Hospitals, Department of Pharmacy, "Unit Dose Dispensing and Drug Administration D i v i s i o n P o l i c y " , 1970. 111. "The Unit Dose System at The University of Kentucky Medical Center", unpublished information. 112. Beck, A.V., H o s p i t a l Top., 46, 49 (1968). 113. Richards, S.E., "Designing and Evaluating a Direct Physicians' Order to the Pharmacy i n St. Paul's H o s p i t a l " , unpublished report submitted i n p a r t i a l f u l f i l m e n t of the requirements of Pharmacy Residency Program, Vancouver, B.C, Canada, 1972. 114. Z e l l e r s , D.D. and Derewicz, H.J., Am. J . Hosp. Pharm., 2_4, 550 (1967). 115. Freund, R.G., Hospitals, 40, 152 (Sept. 16, 1966). 116. The Ohio State University Hospitals, Department of Pharmacy, "Admixture Service P o l i c y " , 1968. 117. University H o s p i t a l , University of Michigan, information received on author's questionnaire, Mar. 1, 1973. 118. Shands Teaching Hospital and C l i n i c s , University of F l o r i d a , idnaformation received on author's questionnaire, Feb. 27, 1973. 119. Ravin, R.L., Hosp. Formul. Manage., _3» 3 5 (1968). 120. Wuest, J.R. , Drug I n t e l l . C l i n . Pharm., j+, 183 (1970). 121. Ravin, R.L., Drug I n t e l l . C l i n . Pharm., 4_, 97 (1970). 122. Ravin, R.L., Drug I n t e l l . C l i n . Pharm., _4, 41 (1970). 123. Murphy, C , Director of I.V. Therapy Service, St. Paul's H o s p i t a l , personal communication, 1973. 124. Sherrin, T.P., M i l l e r , W.A. and L a t i o l a i s , C.J., Am. J . Hosp. Pharm., 29, 1013 (1972). 128 125. B e l l , J.E., Bouchard, V.E., South, J.C. and Duffy, Sr. M.G., Am. J . Hosp. Pharm., 30, 220 (1973). 126. B e l l , J.E., Bouchard, V.E., South, J.C. and Duffy, Sr. M.G., Am. J . Hosp. Pharm., 30, 300 (1973). APPENDIX I PHYSICIAN-'S ORDER FORM—ST. PAUL'S HOSPITAL 129 Fo( 24 ST. PAUL'S HOSPITAL P H Y S I C I A N ' S O R D E R S (g) Drug Profile: -44 C Date Noted Req'n Sent Orders 1 1 1 1 c APPENDIX II MEDICATION RECORD—UNIVERSITY OF KENTUCKY 130 UNIVERSITY HOSPITAL UNIVERSITY OF KENTUCKY MEDICAL. CENTER Lexington, Kentucky MEDICATION RECORD APPENDIX III 131 MEDICATION MEMORANDUM —ST. PAUL'S HOSPITAL Ph. "'3 - PHARMACY DEPARTMENT - ST. PAUL'S HOSPITAL MEDICATION MEMORANDUM TO: Ward Date _ Time RE: Hospital No. PLEASE NOTE: Reason for change: Doctor's Request Clarification Only Action to be taken by the Ward: Attach to chart as reminder to Doctor Change Chart, Kardex and Medication Card (This form may be attached to chart for future reference) Pharmacist APPENDIX IV(a) MEDICATION RECORD—UNIVERSITY OF WISCONSIN A L L E R G I E S DIAGNOSIS OR SURGICAL PROCEDURE WT: AGE: U N I V E R S I T Y O F WISCONSIN H O S P I T A L S S C H E D U L E D M E D I C A T I O N S D A T E D A T E | D A T E D A T E i D A T E T D A T E CHARGE START DATE STOP DATE TIME MEDICATION DOSE R I I I I j I I I ! i i j | | | | I ] I I i I | I I I I i | i I I UWH-513 112/86) ROOM N A M E S E R V I C E A X APPENDIX IV(b) MEDICATION RECORD—UNIVERSITY OF WISCONSIN N A M E C H G . P H R N T I M E D A T E N O N - R E C U R R 1 N G M E D I C A T I O N S C H G . S T A R T D A T E S T O P D A T E D A T E D A T E D A T E D A T E D A T E D A T E P R N M E D I C A T I O N S P O I M P O 1M P O I M P O I M — P O I M P O I M P O I M P H A R M A C Y D E P T . U S E O N L Y P O I M P O I M P O I M P O I M P O I M P O I M P O I M P O I M UNIVERSITY OF WISCONSIN HOSPITALS NON-SCHEDULED MEDICATIONS to Lo 134 APPENDIX V. DRUGS NOT GIVEN NOTICE — UNIVERSITY OF KENTUCKY MEDICAL CENTER DRUGS NOT GIVEN NOTICE Patient's name Room Number Date Refused NPO Discontinued Discharged Drug Not Ordered Incorrect Dosage Expired Patient Not Available O.R. O.T. P.T. X-Ray Drug(s): Comments: Nurse's Signature N-34 135 APPENDIX VI. NOTICE OF AUTOMATIC STOP ORDER — UNIVERSITY OF KENTUCKY MEDICAL CENTER NOTICE OF AUTOMATIC STOP ORDER As of midnight the following drug(s) w i l l be discontinued automatically unless a new order is written. Patient's Name Room No. Name Date UH Form PCS14 APPENDIX VIII 137 (From: Am. J. Hosp. Pharm., 28, 94 (1971) THE MOSES H. CONE MEMORIAL HOSPITAL Addressograph Imprint Here I.V. ORDER CARD PHARMACY DEPARTMENT I.V. NO. 1 T I K E NEEDED TYPE AND SIZE I.V. ... . ADDITIVES (1) (2) (3) (4) TV Nn a TTMF Kv.v.nv.n PREPARED BY: CHECKED BY: TYPE i v NO 9. Trf.iv. NF.F.nrcn AND STZF. TV TYPE ADDTTTVF.S (1) ANTn STZF. TV 19) Annrnvrcs ( i ) (s ) (2) (3) PRF.PARF.D RV- P H E C K P n B Y -(4) PRF.Sr.RTRF.Tl RV-PREPARED EY: CHECKED BY: STONED RY- PATF COMMENTS: (Circle Desired Comments) NEED I.V. NURSE STAT q.6hrs. q.l2hrs. OTHERS: ADD ON SOLUTION q.4hrs. q.8hra. q.24hrs. Phar 31 APPENDIX IX 138 PHARMACEUTICAL SERVICE RECORD—MEMORIAL HOSPITAL OF LONG BEACH •MS O U M H T t T ' Teinp. ns x f i M r a u n • U N Hl» S M * . Met POUMlWM II.I.C. i ia> ChlorIM W.I.C. I IO> ca tn'mn - #* •«*> LympfiKytM nnnm U M Q k l M M , |HIM«MU tfrk AcW W.tiffl|ilw!# tl 1 tarn SOW Pra|r«Mii«cftts M n t t M I l AW rimt P M t t o t t t l . W M k , ta* •tttutTsts O w o u m.i..i..i P l U t f i w.u M.I. • i.e. 1» D M ! Mticowtil<M/On< PrgtftranMil iM-wntla M T I I M T H I S T O R Y ; D R U C S A N O O I U A M S j RROORSSS KOTO Uwt • Bant MK • Kidn.r • O n i | I n h r K t l o n O I m N » f W t T Q A M T I S I O T I C S I M U T i y i T T — B A T S : / / / Aattctftla O u c U l M O U f W l U l W l M l PtOcl lHll C M I M I m t i M * * PotymyilR I Strt^iWIJclH T t t n c j e l l M • M M c f l l i a : (MACMOmC: X - R A Y , HOMY. US N A R C O T I C S , M O S I O I , S I N U S DOSSS A M D W m i l l O A T C SMTV N A R C O T I C S , I I D S I O t , S I H 6 L S DOSSS A M D SUmliS O A T I u r i fif»W»»/rti,»C»d/*«C<rt MS/ltaRHMIiw M l m t o O n Draft • O U c M r p ttt • Si»» M R Q D I A G N O S I S mtuo •CM.invtTifs AW ULIMIII R I O M l T o n • From: Smith, W. E. and Mackewicz, D. W., in "Perspectives in Cl i n i c a l Pharmacy", 1st. Ed., edited by Franke, D. E. and Whitney, H. A. K., Drug Intelligence Publications, Hamilton, 111., 1972, p. 102. APPENDIX X PHARMACY SHEET—ST. PAUL'S HOSPITAL 139 Ph. #1 PHARMACY SHEET (Not a Permanent Record) This communication is provided as information only and may or may not be clinically significant. In many cases the physician will already be aware of this information and its implications. In particular, the problems and interpretation of drug interactions are complex and must be viewed in perspective. The term "interaction" is not necessarily synonymous with "incompatibility" or "contraindication". For further clarification, see the reverse side. Where information has been useful, or if a physician wishes to comment please note this in the space provided. Pharmacist Physician's Comments or Assessment, if any Please see reverse side 

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