The King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Saudi Arabia was the first hospital in the Middle East to implement medication management via Automated Dispensing Cabinets (ADCs) and has continued to lead the way with deploying the solution in challenging environments where the predictability of activity and medication turnover, risk of stock-outs, and opportunities for station replenishment are difficult to predict and to realise effectively.
The load managed by the Pharmaceutical Care Division of the hospital is huge. KFSH&RC has 1,852 inpatient beds, receives 1.3 million outpatient visits and 12,601 inpatient admissions yearly, and its Emergency Department and Admissions Ward serves the heart of metropolitan Riyadh.
The hospital has successfully integrated over 100 ADCs in inpatient areas. These units streamline medication distribution, link nursing and pharmacy workflows, help support regulatory compliance efforts and reduce preventable medication errors.
One of the advantages of ADCs is that because they can be integrated into Computerised Practitioner Order Entry (CPOE) systems and to the patient’s Electronic Medication Administration Record and Electronic Medical Record, they can help reduce the risk of harm to patients by reducing preventable medication errors before they reach the bedside, and importantly for acute care areas they can help clinicians to start patients’ therapies faster by reducing time to first dose as medications are accessed by entering the patient’s ID number and the ADC then opens the correct compartment where the medication is held – this reduces the need for searching through cupboards and shelves, and hunting for medications – a very time consuming activity that takes clinicians away from their primary role of caring for the patient. On average it takes about four steps, and only five seconds to find and take the correct medication from an ADC.
ADCs at KFSH&RC are Enterprise Server connected; this means that via one database the Pharmaceutical Care Division can apply the hospital’s formulary across the entire organisation and can manage user information and user privileges across multiple units. Ideally this information should be web-based with unlimited access to the system and reports for authorised users.
KFSH&RC has successfully extended ADC usage to the Emergency Department. This is an area that has always been a challenge for hospital pharmacies due to the unpredictability of patient load, the variety of disease states and patient issues likely to present and the lack of a ‘fixed’ census in an environment, which may have patients on trolleys as well as beds and also employ virtual beds to manage patient location before formal admission to the hospital. All of this makes forecasting for which line-medications need to be stocked extremely challenging, and furthermore, makes maintaining adequate stock levels in the unit difficult due to the unpredictable patient census and acuity level.
The KFSH&RC Pharmaceutical Care Division placed 27 ADCs in the Emergency Department. As ADCs utilise space and can carry multiple small items in single dose pockets, the Emergency Department has approximately 1,600 line-item medications at its immediate disposal for treatment. Of course, powerful analgesia is commonly required in the Emergency Department for trauma or emergent surgical and medical conditions. These require secure storage, and documented usage trails. ADCs allow securement of narcotics and other controlled drugs through clinician access codes, two clinician electronic documentation or ‘sign-outs’ for controlled medications, and fingerprint recognition for authentication. The KFSH&RC Emergency Department carries over 200 controlled drugs in its ADCs, and premixed narcotics are managed in a locked refrigerator, which is integrated into the main ADC unit for user access.
Another pressing need in the Emergency Department is for first dose antibiotics to be given as soon as possible, also Emergency Department clinicians commonly administer rapid therapy bundles rather than single-medication treatments. The KFSH&RC Pharmaceutical Care Division manage this process through the deployment of ‘virtual-kits’ and ‘treatment-bundles’ for specific therapies. These are stored in ‘Cubies’ which allow access to either a complete mixing set for IV medications (for example antibiotic vial, water for injections, normal saline bag for dilution), or open several Cubies during only one station visit to allow the clinician to gather all the parts of the treatment-bundle quickly and efficiently.
Therefore, the physical medication needs of clinicians and patients in the Emergency Department can be met through ADCs, but as noted earlier the real challenge of this environment and that of Emergency Virtual Wards and Admission Units for medication management is the unpredictability of the patient workload. Differing needs, acuity and simple numbers of patients are all hard to predict. ADCs, and their related hardware such as Cubies and specialist-integrated refrigerators are all powerful aids, but it is the readily usable data that Enterprise Server networked ADCs create that make all the difference to ensuring the right types of medication are always available in sufficient volumes. In KFSH&RC ‘stock-outs’ of medications are avoided through a replenishment strategy based on activity in ED rather than on the more simple forecasting that might be used to plan for stock replenishment in more conventional care areas. Indeed, traditional planning for location and number of dispensing units also cannot be applied in the Emergency Department, instead new metrics based on medicine stock items, drug utilisation, doses dispensed, and patient turnover help manage stock and optimise ADC location.
In conclusion, the role of automation continues to grow and evolve in acute care as it does in other areas such as outpatients and beyond the main hospital environment. The challenges for each of these areas is different but the ability to gather data, and to turn that data into readily useable information to predict, plan, implement and evaluate medication management strategies (see Figure 1 for an example of how trends are reported from ADCs) is the real key to improvements in safety and in efficiency.
Effective hardware can take care of a lot of the everyday issues of access to, control of, and safeguarding of medications but it is the connecting together of networked devices through Enterprise Servers that makes the role of automation so central to modern healthcare delivery.