Transcript Pharmacy - UZ Brussel

Pharmacy: Distribution and
tarification of painkillers: a practical
approach
Claudine Ligneel
Hospital pharmacist
Pain control at the OT
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Narcotics in (tool)boxes
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In UZ Brussel since 2008
Narcotic box
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2 boxes with same content for each
anaesthesiologist or resident
Narcotic box
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Boxes are locked with 2 padlocks (secret
code allocated by pharmacist)
Narcotic box
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Prescriptions are left in the box - for Belgium original,
handwritten, with the amounts in full writing, dated and
signed and with complete identification of prescriber
Narcotic box
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To be refilled, boxes are put in a
dedicated and locked place at the OT
secretary
Boxes are brought 2 x/week to the
pharmacy
1 box in use, the other at the pharmacy
Narcotic box
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Repleting of narcotics is controlled by a
pharmacist and boxes are returned to OT next day
Narcotic box
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If prescription is not valid, no medication
is repleted and box returns with notice
Narcotic box
Narcotic box
PRO
CON
User friendly
Time consuming for
pharmacist to set-up (great
turnover of residents)
Manual prescriptions on
the moment of use
Tarification (manual)
Safe (2 lockers – locked
area)
Boxes lost
controlled by pharmacist
2x/week
Time consuming to refill
Self responsability – self
control
History of use difficult to
trace
cheap
Pain control at the OT
 Automated Dispensing System (Vanas)
replacing the narcotic boxes ?
PRO
CON
Tarification on the spot
Still need for manual
prescriptions (Belgian law)
Turn over of residents
Easier refill
Shared responsability
Completely electronic
control of medication
stock
Time consuming to pick
the narcotics
patient/patient
Safe storage
expensive
Pain control at the OT
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medication in 2 reanimation trolleys
in the medication room at OT
Pain control at the OT
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Other painkillers in trolleys (2/OT room)
 2 identical medication drawers (1 in use at OT
and 1 refilled in the medication room at OT)
Other painkillers in trolleys
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Anaesthesiologist ticks used medication
on preprinted activity sheet
Other painkillers in trolleys
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Tarification at OT through scanning patients’
barcode and barcodes of used medication
Other painkillers in trolleys
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Picking list of used medication
Pain control at the OT
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Medication repleted in the medication cabinet,
locked with secret code
Pain control at the PACU
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Automated Dispensing System (Vanas)
 login with fingerprint
Automated Dispensing System (Vanas)
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Patient selection: scan barcode on
patient label
Prescriber selection: PC/touchscreen
Medication selection: PC/touchscreen
LED-indication shows the user which
drawer can be opened
After closing the drawer, the system
makes the link with the pharmacy
system for tarification of used
medication
Automated Dispensing System (Vanas)
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2 different types of dispensing
 the whole drawer in which the selected
medication is placed can be opened
Automated Dispensing System (Vanas)
Automated Dispensing System (Vanas)
 The drawer opens only for the amount of
medication selected = SAFER + 100%
TRACEABILITY(narcotics, expensive
medication)
Automated Dispensing System (Vanas)
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Next working day a picking list is printed in
the pharmacy
Automated Dispensing System (Vanas)
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Dispenser repleted by the pharmacy
assistant responsible for
anaesthesiology
Narcotics: print at the PACU of use of all
narcotics/patiënt/day
to be copied in handwriting, with the
units in full writing, signed and dated
and with complete identification of
prescriber
Pharmacy only refills the narcotics upon
reception of the handwritten
Automated Dispensing System (Vanas)
Automated Dispensing System (Vanas)
iMD soft
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Software system for anaesthesiologists
(Israël)
Implemented at OT and pediatric ICU
In progress for PACU
iMD soft – medication use
iMD soft
iMD soft – report in EMD
iMD soft Anesthesiology report
iMD soft - report in EMD
iMD soft
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Link with logistic system
 automated control of stocks (ERP)
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Link with tarification system (UZB APB)
Pain control starting at the PACU
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Patient Controlled Anesthesia
 30 pumps at OT, 6 pumps at Delivery Room
 New type implemented in October 2012
 anaesthesiology team did the data input in
the pumps referring to the standing orders
 standing order document for each type of PCA
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PCIA
PCEA
PCPA/Elastomere pump (CPNB = continuous
perifere nerve block)
Patient Controlled Anesthesia
Pain control starting at the PACU
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Patient Controlled Anesthesia
 3 standardized formulations
R/ Dipidolor 20mg/2ml amp X10 amp
Dehydrobenzperidol (DHPB) 5mg/2ml X1 amp
NaCl 0,9% 78ml
R/ Morfine 10mg/1ml amp X10 amp
Dehydrobenzperidol 5mg/2ml amp X1 amp
NaCl 0,9% 88ml
R/ Naropin 2mg/ml 196ml
Sufenta Forte 50µg/1ml amp 4ml
2 infusions are prepared for PCEA therapy
(except 1 for caeserian section), 1 infusion for
PCIA therapy
Pain control starting at the PACU
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Patient Controlled Anesthesia
 Nurse from the APS (Acute Pain Service) team
prepares the mixtures on the PACU holding
 Aseptic
 Preprinted label with content on each side of
infusion
 Patiënt label
 Preparers’ initials and date on label
 Medication taken from the Vanas at PACU
Patient Controlled Anesthesia
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APS nurse installs the pump according
standing order document
Tarification of PCA in the system by APS
nurse
At PACU pumps are started
standing order document goes with the
pump to the nursing unit
Traceability of the pumps
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Each PCA pump has a number
- per Day a log (manual)
- global logbook (manual)
A follow-up prescription document goes to
the APS team
Each day the APS team follows all the
patiënts with a pump
if needed, an extra infusion is prepared
APS team returns used pumps and
completes the logbooks
Pain control starting at the PACU
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In 2012 study with the pharmacy
(Masterstudy Jelle Marcoux to achieve
the ManaMa for Hospital Pharmacist)
 evaluation of quality, economic and safety
issues concerning central preparation at the
pharmacy of the standard painmixtures used
for the PCA
 evaluation of the quality, economic and safety
issues with the implementation of new PCA
pumps
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CIVA = Central IntraVenous Admixture
Pharmacy study for CIVA - PRO
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Time saving for nursing team
 No time needed for the preparation of the
mixtures because preparations ready to use at
the PACU in the Vanas
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patiënt safety (literature documented)
 aseptic preparation in controlled conditions
(LAF)
 No interruptions during preparation of pain
mixtures
 Standardized preparation techniques
 trained personnel / pharmacist supervision
Pharmacy study for CIVA- CON
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more stability studies needed for some
mixtures
Material cost (LAF)
Time consuming for the pharmacy:
training, preparation, release by
pharmacist, quality control, paperwork
Responsability of the pharmacy at the
PACU: supervision of stock conditions,
stock and expiry dates
Pain control on the wards
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Individual electronic prescription
The system prints a medication order in
the pharmacy for the same day and 2
days beyond
Ordering system reviews the patiënts’
stock each day until stop order and
makes new orders if needed
A hospital logistic team brings the
medication to the ward
Urgent orders are possible
Electronic prescription
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Voorbeeld
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Voorbeeld
Medication selection
On Hospital Formulary List
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Voorbeeld
Information
at moment of prescribing
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Pain control on the wards
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Individual electronic prescription
 Orders are signed electronically by the
physician + secured by electronic timestamp
 Tarification at the pharmacy after
verification of each order
 bad prescription – cancellation order
 ordering too much - amount of
medication can be changed
Individual electronic prescription
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For narcotics additional pharmacy
control
 each printed order for narcotics is also
printed at the nursing unit
 Responsible physician makes a handwritten
and countersigned copy of the electronic
narcotic order on the order document
 Narcotics only dispensed at pharmacy with
the handwritten prescription and with
signatures of dispenser and receiver as
control
Individual electronic prescription
Individual electronic prescription
Pain control on the wards
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Vanas on Emergency Department (4)
Medication cabinets on ICU
Emergency Medication cabinets
 Each nursing unit
 Discarding medications by selecting the
patient on the PC screen and scanning the
barcode in the cabinet that is linked to the
medication (tarification on the spot)
 Contents is determined by the Head Physician
of the specific unit
Emergency Medication cabinet
Emergency Medication cabinet
Emergency Medication cabinet
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When to use?
 In case of urgent therapy
 Outside the opening hours of the pharmacy
 Analgesic and other medication in fuction of
parameters or in need
 on standing order (for example extra
medication for PCA pump)
 Preferred for narcotics (less patiënt overstock)
Emergency Medication cabinet
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Next working day a picking list is
printed at the pharmacy
A pharmacy assistant repletes
1 prescription/patiënt/day for all
scanned narcotics
Only repleting narcotics against the
handwritten copy
Receiver at the unit countersigns against
the delivery and places narcotics in the
cabinet
Centralised Emergency Medication
cabinet
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Automated Dispensing System (Vanas)
 Implemented since 21 May 2013
 810 references
 Narcotics not yet included
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When to use ?
 urgent medication outside the opening hours
and if not available in other medication
cabinets
Centralised Emergency medication
cabinet
Centralised Emergency medication
cabinet
1. Login with personal UZ badge
Centralised Emergency medication
cabinet
2. Selection of nursing unit
3. Patient selection (link with physician)
Centralised Emergency medication
cabinet
4. Select medication on touchscreen
Centralised Emergency medication
cabinet
5. Controlled delivery
6. Tarification upon closure of the drawer
Questions?
Many thanks to all persons
who helped me with this
presentation