An inspirational visit to the pharmacy of the Centre Hospitalier de Valenciennes
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1 Bekijk de nieuwsbrief online als deze niet correct wordt weergegeven. hict visits An inspirational visit to the pharmacy of the Centre Hospitalier de Valenciennes On August 22nd 2014, a hict team crossed the border to France to visit the Centre Hospitalier de Valenciennes. Although Valenciennes may be a less known French city in Belgium, the hospital is with almost 2000 beds one of the larger players in France. The visit was aimed to strengthen hict s unique approach of optimization projects for pharmacies as a customized solution for the entire hospital. Quality and safety purpose The visit was guided by Etienne Cousein, Head of the pharmacy medication department, currently finishing his PhD in efficiency and safety of the medication process. Etienne Cousein shared passionately the genesis of the 'best practice' hospital pharmacy in the CH de Valenciennes. He explained in one sentence the purpose of the hospital project: "We are not satisfied with the 10% error in the medication process as common in hospitals, we want to obtain error rates applicable in the aviation industry of 1 in 1 million." In a few hours, we got the chance to see in detail how this goal was converted into processes, systems, behavior and culture. Stepwise approach In late 2006 the CH de Valenciennes started thinking about automation and unidoses. Three years later, in 2009, the (Swisslog) pharmacy robot was operational and started with the delivery of some 40 beds with patient-specific medication rings. Now, 500 of the 900 acute patients are supplied through the hospital pharmacy automated systems per 24h. In addition the long stay wards patients are weekly supplied with 7 rings per patient. Besides the central robot, a software-controlled Pyxis cabinet of CareFusion is installed on each floor. This form of customization for different wards from unidoses from the pharmacy on the one hand to all manual processing at the ward on the other hand is the power of the model as realized in Valenciennes.
2 Patient safety and optimization In Valenciennes the starting premise wasn t the implementation of a pharmacy robot or saving of staff. The goal was and is patient safety and optimal support of the care process. This choice has several consequences. Thus, the pharmacy automation project isn t a project of the pharmacy only, but is realized for, by and with the complete hospital. Doctors and nurses are involved to optimize the medication process in connection with the care process. Since automation was not a goal in itself the result isn t a full flesh automation of all wards. For example: the choice was made for little automation but intensive decentralized support by the pharmacy on the intensive services. Another example is that pharmacists are now performing medication reconciliation in the emergency department and are using a clinical decision support system during the prescription checking process to ensure medication management safety. Consequently the project did not result in high savings of FTEs, but new roles were put in places for different types of staff with other tasks. All aimed at the improvement of the quality of the medication process. ICT as driver The parallel IT project of the implementation of a new Hospital Information System and the Electronic Medical Prescription module has been an important driver to achieve the desired results of the pharmacy project. The new quality-oriented pharmacy requires pharmacists to have access to all data of the patients. Information from both the nursing and the medical record is important in the drug monitoring of patients. The successful integration of the various health care players asks for perfectly aligned and customized IT solutions. Furthermore such a change requires commitment from everyone involved with the patient to learn to use the new tools. This project could not have succeeded if it had not been supported by the whole hospital. Different degrees of automation Important determinants for the degree of automation of each ward are: 1. the variability in the prescriptions 2. the time between the prescription and administration The greater the variability in prescribed medication per patient per day, the later the medication rings should be created in order to accommodate all the changes. If there are too many changes to the prescriptions, the decentralized cabinet will be used frequently and should be placed closer to the caregivers. Customization to the different care processes asks to adjust the turnaround time of the medication process. The time between prescribing and administering can vary greatly between wards: from prescribing for days in advance (geriatrics) to administering before prescribing (ER). The shorter the time between prescription and administration, the less suitable the solution of a, still slow, robot. In Valenciennes, the prime examples of the different solutions are implemented.
3 The unidose processes in detail The unidose process already starts at the reception of the medication in the pharmacy. The blisters are placed in closed canisters with a RFID tag. When these canisters are placed in the robot, the robot identifies the medication based on the RFID tag. Then the blisters are cut into unidoses by the robot and packed in bags that are automatically stored. When the robot receives the command to make a particular prescription, the bags are 'picked' and joined to one ring. Next, a label with the patient s name, the administration data, and other useful information are added to the ring. An average drug ring for one patient for one day consists of 12 to 14 single-doses. The non-packable medication, such as large bottles of syrup, some ampoules or ointments, still needs to be added manually. This medication is taken by the pharmacy staff from the carousel (Rotomat) and placed with the drug ring in the box for that patient. As with the medication ring, a label with the name of the patient is added to the non-wrapped medication. This will be complemented with a barcode to close the medication circle completely with bedside scanning.
4 Acute services The pharmacy of the CH de Valenciennes has two Swisslog robots which have almost the same content. This doubling offers sufficient capacity to provide all the medication rings. The robots are working 4 to 5 hours per day to create the medication rings for 500 patients. Next, these robots cut the blisters and store the unidoses all day long. In the morning, the robot starts cutting and storing the bags on one side of the robot. Around noon the picking starts and medication rings are prepared for the acute wards on the other side of the robot. A second picking round starts in the late afternoon to absorb changes in the prescriptions and to process the new admissions. In the course of the day the returns are offered to the system and at night they are automatically stored by the robot. If the pharmacy would be working with one robot it would be picking up to 10 hours a day, what might give problems to cut and store the new medication timely. Long stay departments The robot prepares the medication for an entire week at once. Thus, there are seven medication rings created per patient that come together out of the machine. The Intensive Care services The flow of the medication in the robot is the same as for acute services. At the wards, additional medication is made available in cabinets. The robot cannot offer the desired support for the intensive care services (emergencies, operating theater, intensive care). Alternatively decentralized cabinets are used. These cabinets are connected to the IT system and hence the pharmacist can see when he must fill each cabinet. In this case, only the SW integration part of the entire pharmacy project is implemented.
5 Staff In the past pharmacists were only dedicated to paper order checking with a few assistants and the wards were supplied in bulk by the pharmacy when required. There was no further follow-up and the nurses at the ward had to prepare the medication. Currently the pharmacy is working with 10 pharmacists and 16 assistants. 4 pharmacists are dedicated to check and analyze the electronic prescriptions in the morning and 2 in the afternoon. As a support tool, the pharmacists have full access to the EHR. Three assistants ensure the unit dose delivery, their main job being to check the coherence between the prescriptions and the medication ring, the patient room number and whether there are empty or damaged bags on the ring. One to two pharmacy assistants are in charge of the daily supply for the decentralized cabinets. In the future, the pharmacy would like to expand with 6 to 8 pharmacists to follow the patients closely at the ward and to check and, if necessary, adjust the prescriptions in consultation with the doctors and the nurses. In addition to pharmacists, the pharmacy is expanded with technical staff to take care of the functioning of the robot and the supporting ICT. The main lessons we learned from this visit: Choose care process specific optimization allowing for customization per type of care (acute, long stay...) and a customized solution for each ward. A robotic solution should not be a goal in itself. Develop for optimization of care and involve the nurses and doctors. Pharmacy automation is not a standalone project, but a project for the entire hospital. Deploy incrementally. Don t aim to develop a solution for the whole hospital at once. Start with one ward and follow the process very closely. Set clear goals but don t hold on to a too strict vision of the solution in advance. Let the patient and the care process be a guidance to achieve an optimal solution. IT is a very important factor for success for the optimization of the pharmacy process, since all patient information must be integrated. Finally, the solutions chosen by the CH de Valenciennes are not necessarily suitable and affordable for all hospitals. Valenciennes is a large hospital and as such having the numbers and resources and to realize such an example. Notwithstanding both large as smaller hospitals can learn and be inspired from the approach chosen in Valenciennes. We conclude with our gratitude to Etienne Cousein for the inspirational way he showed us his masterpiece. On behalf of hict, Jan Verstraete, Peter Deboutte and Rianne Welvaarts You re inspired and looking for more information on the subject? Then you can find a related video here: Claude-Bernard-developpee-par-RESIP_v221.html EZELSTRAAT 69 B BRUGGE BELGIUM PHONE: RPR/RPM: INFO@HICT.COM
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