Claude Parnell from Geisinger an Aethon customer discusses why medication tracking should be part of every hospital pharmacy’s information system. There is also a detailed write up on the use of TUGs, RFID and MedEx real-time medication tracking software at Geisinger’s Wyoming Valley location.
WOW! Or is it MOW?
Claude Parnell wants to know why it is that people can track a $5 pair of socks at every stopping point between Amazon.com and their house, but most hospitals can’t track medications between the pharmacy department and the bedside -even those that cost $10,000 or more per dose.
For Parnell, operations director for system therapeutics at Geisinger Health System, Danville, Pa., it’s on the verge of being a rhetorical question. Geisinger is now deploying a combination of robots, pneumatic tubes, and software to track medications from the moment the order is entered to the time it’s administered to the patient. (See below.) The final piece of the puzzle is an interface with its electronic health record system so that nurses-or any other hospital staff, for that matter-can find out the status of any medication from any workstation.
“Whether it’s this technology or another, the time has come for tracking to be applied on a widespread basis,” Parnell says. “I see a manifold benefit to the patients we service, and it helps me get such a better handle on my operation because I know how long it takes orders to get through the pharmacy system.”
Medication carts have evolved dramatically in the past several years, and the most advanced ones now function as full medication administration workstations, with on-board bar code readers, tracking software that’s integrated with the hospital’s pharmacy information system and/or electronic health record, and full computing capabilities so that nurses can chart at the bedside. Their security measures can include passwords for each user, swipe cards, and even biometric identification. Workstations on wheels, or “WOWs,” which once were largely confined to toting portable computers, are fast becoming medication dispensing carts on wheels. Can a new acronym be far behind?
Several factors may decide. For the latest carts to work as intended, users must pay even more attention than usual to logistics and ergonomics, says Erin Sparnon, senior project officer at the ECRI Institute, Plymouth Meeting, Pa., which assesses medical technology.
The sophistication of carts varies widely, she says, as does the software that operates them. Some have lots of different options for controlled access; others have just two modes: locked and unlocked.
She recommends designing the medication workflow first, before looking at either carts or software. The questions to consider include:
* Which medications will be transported in the carts?
* How will they be stocked? Will they be loaded onto the carts directly from the pharmacy, or from dispensing cabinets on the floors?
* What access controls are needed?
* If bedside barcoding will be used, how will the barcodes get onto the patients and the medications? (Sparnon says that even though this question isn’t related to cart or software selection, it can torpedo a medication-cart deployment if it’s not answered adequately.)
Once the workflow is designed, the hospital can select a cart and software to support it. “If the hardware or your technology solution doesn’t support the workflow, nurses will end up using workarounds,” Sparnon says.
Ocean Medical Center, Brick, N.J., didn’t want its computerized medication carts to be known as COWs, so it has proactively dubbed them “BMWs”-bedside mobile workstations. But whatever clinicians call them, the carts are helping the nursing staff save significant time and steps and improve patient safety, says Joan Harvey, nurse educator. She calls them a “portable nurses’ station.”
The carts come from Rubbermaid and look something like “garbage cans with pulls,” Harvey says. They’re equipped with scanning wands for bar-coded medication administration, and a drawer for each patient’s medication. The carts are stocked from dispensing cabinets for each medication pass, rather than for the whole day.
Each nurse on a shift gets his or her own cart. There are seven nurses per shift per floor, and the carts are in almost constant use for distributing medications and doing documentation. It’s difficult to keep the batteries charged, but Harvey says the carts are plugged in at every opportunity.
The carts lock automatically if they’re left unattended. “From a regulatory standpoint, the medication security is a home run,” Harvey says. “We never have to worry about meds sitting unsecured.”
The end users were deeply involved in cart selection and put many models through their paces before making a final choice, Harvey says. “We needed one sturdy enough for the computer and bar-code wand,” she says. “And it had to be able to take a licking, to be bashed into the wall, or hit the side of the bed or the door jamb.” The carts also had to be the right height and maneuverable enough so that nurses didn’t have to twist in order to steer them. The selected carts have adjustable height.
Since deployment of the carts, wrong-patient medication errors have dropped to one percent. “We have absolutely positively changed nursing practice because of the cart,” Harvey says. “Nurses spend more time with patients because they can document care right at the bedside.”
One of the challenges of a mobile automated solution, for any purpose, is keeping the darn thing mobile. Northeast Georgia Health System, Gainesville, Ga., depends on workstations-on-wheels because its older building doesn’t have space for computers in each room. The medications themselves are delivered to nurse servers outside each room, but the carts hold a workstation and a barcode scanner for medication administration. Nurses use the carts to document in the rooms. Their single biggest gripe was that the batteries couldn’t last for a full shift, so the organization switched to a battery that can be swapped out during a shift and charged separately from the cart.
“The batteries give us a little more flexibility and less clutter,” says Mary Martin, chief nursing informatics officer. The flagship hospital has mobile carts deployed throughout, even in a newer surgical pavilion that also has in-room computers.
The batteries have a charging station of their own. The carts are in almost continuous use, and are stored in small wall alcoves when they’re not.
Test drive your CAB
CentraState Medical Center, Freehold, N.J., is on its second round of medication carts (called CABs, or “computers at bedside”), having rolled out the first version in 2004. CIO Indranil Ganguly says the hospital has learned several lessons from its adventures in medication decentralization, starting with the selection process.
“When the vendors started coming at us, we realized that we didn’t know what we didn’t know,” Ganguly says. After online research on five or six options, the hospital narrowed its choice to three vendors and had them come out to let the nursing staff test-drive the products. It seemed like there was a clear winner with 60 percent of the vote. “It didn’t occur to us that if 60 percent of the nurses liked a particular cart, that meant that 40 percent didn’t,” he says.
The nurses started demanding tweaks right away. To further complicate matters, the carts that were delivered weren’t the ones they had tested, but were larger and heavier. It was difficult to push them across the thresholds of the rooms, so they were frequently left in the hallways while nurses visited the patients, somewhat defeating the purpose. The carts were widely hated.
Three years ago, after suffering for several years, CentraState did a complete refresh, and found that cart technology had made major strides. “We did a much broader look at 15 vendors and narrowed it to four,” Ganguly says. “The materials are lighter, they’re easier to maneuver, and there are a lot more options for computer real estate. A lot of them have power assist for raising and lowering, and the locking mechanisms are much better.”
While there was no way to mimic the abuse that the carts get day to day, the nurses tested their durability by banging the drawers as much as possible. After getting consensus on a model and a configuration, CentraState happily junked what remained of its old carts, which had taken too much of a beating to have any further use. The hospital also renovated the nursing units to remove the thresholds, further facilitating cart use. Ganguly recommends test-driving the exact cart that’s going to be ordered, even retesting it after having options added.
A new entrant on the mobile medications market-the Medrover cart from Swisslog, a Swiss company with North American headquarters in Denver-claims to be the only mobile device with full auditing capabilities down to the level of individual medications. Inventor Bill Park and his partner created a company to develop the cart in 2008, and then sold in 2011 to Swisslog, which also makes automated materials transport systems.
The cart itself was designed by a nurse. It looks a bit like a rolling trash can, Park says, but it maneuvers easily and has up to 108 storage bins depending on configuration. Each can unlock individually. When not in use, it attaches to a wall-mounted docking station and needs a password to undock it, so it can serve as an automated dispensing cabinet when it’s not on the move. Software audits every access to the medications, and the cart incorporates a bar-code reader for bedside medication administration.
It’s being piloted at Bacharach Rehabilitation Institute, Pomona, N.J. Nurses have decreased their medication administration time from two hours per day to one hour, and are saving a total of 1.5 hours per shift with fewer trips to dispensing cabinets.
The Rover software uses the Corepoint integration engine to interface easily with other clinical systems, Park says. So far, the company has successfully interfaces with systems from Meditech, Healthland, and Siemens. Park prefers not to divulge pricing information, though he says the Medrover can be purchased or leased, and that Bachrach saved 40 percent on the total cost of ownership over five years, compared with its previous medication distribution system.
When it comes time to select an advanced medication cart, ask these questions:
1 How will your facility use them? Will they be used on all units? Will they need to support dispensing of all types of medications, or just some?
2 How usable are the carts? Do they maneuver easily? Do the wheels roll easily on carpets, or over room thresholds? Do they fit through all the doors they need to fit through?
3 Are the hallways wide enough to accommodate carts sitting on the side? If not, where will they be stored when not in use?
4 Are there enough outlets to plug them in to recharge?
5 What type of authentication is used?
6 Have other clients successfully interfaced the software to the pharmacy system and/or electronic health record system in use at your facility?
Robots Deliver at Geisinger Health System
For the past eight years, robots have roamed the halls at 485-bed Geisinger Medical Center, Danville, Pa., They shuttle supplies from the materials management department and medications from the pharmacy to patient rooms. They’re programmed with the layout of the buildings, and can have machine-to-machine conversations with the elevators, to summon them and let them know which floor to go to. The robots can avoid obstacles, including people, and can request doors to be opened for them. They continuously transmit their location via Wi-Fi.
The three TUG robots, made by Aethon, Pittsburgh, have the boxy look of a file cabinet on wheels. They have 12 medication drawers, each of which can be loaded with all the drugs needed for a single location. The pharmacy fills the drawers, identifying drugs through barcoding and RFID tags and technicians through a password and a fingerprint. Technicians lock the drawers, program their destinations, and send the robots on their way. The robots only unlock for authorized users.
About a year ago, the robots, and the medication administration system generally, got smarter with addition of MedEx software, also from Aethon, which tracks medications from the time the pharmacy starts filling the order to the time the medication is administered to the patient. MedEx also tracks meds that travel through a pneumatic tube system. “The technology offers a chain of custody feature that frees us from the need to obtain signatures, and gives us much better accountability for who’s receiving narcotics or those $10,000-per-dose medications,” says Claude Parnell, operations director, system therapeutics at Geisinger Health System.
Geisinger recently deployed two more TUG robots, along with the MedEx software, at a second hospital, 182-bed Geisinger Wyoming Valley in Wilkes-Barre, Pa. In the first month, they traveled more than 130 miles.
Most medications in both facilities still travel by pneumatic tube, but the robots are in almost constant use during the day, especially at rush hours. The tubes are used for other departments in addition to pharmacy, and are often backlogged. Pharmacy technicians used to have to deliver meds on foot when the tubes were clogged, or when a medication couldn’t travel by tube for other reasons. The flagship hospital has four tube stations, but Wyoming Valley has only one, making its robots an even more valuable part of the team.
A study at Wyoming Valley before the acquisition of the robots measured the activity of pharmacy technicians, and found that they left the pharmacy 280 times a week, on average, spending 10 minutes per delivery. They were away for a total of 47 hours, or more than a full-time employee’s worth of time. “That is definitely not the best use of a tech’s time,” Parnell says. “I need them in the pharmacy to use their expertise and knowledge, rather than riding the elevator and walking the halls. Employing a robot for that was a no-brainer.”
Technologically, deployment of the robots is relatively simple, says Aethon CEO Aldo Zini. “The hospital doesn’t have to put in any infrastructure to make it work, and it’s very intuitive and simple to use and program and modify,” he says. The company installs the elevator control software, as well as interfaces to the fire alarm system, the pharmacy information system, and any other relevant hospital systems, using HL7 interfaces. A virtual private network, piggybacking on the hospital’s Wi-Fi system, connects the robots to Aethon for monitoring and remote servicing. Aethon also programs the robots with detailed CAD drawings of the facility, so they know how to find their way most efficiently.
The last piece in the puzzle, which Geisinger is currently working on, is to integrate the MedEx software with Geisinger’s Epic electronic health record system. The two currently trade basic order information, and Parnell will add delivery status, with the Epic order number serving as a hyperlink between the two systems.