Nursing and Pharmacy join forces to tighten the medication delivery loop

A patient recovers from triple-bypass surgery on the cardiac surgical intensive care unit. His physician scribbles a medication order onto a carbon form and hands it to a nurse. The nurse rips off the copy and places it in the pharmacy pick-up bin. But darn, she thinks, looking at her watch. They’ve missed the technician’s run for that hour. She has two options: Let the order sit for 50 minutes until he comes back for the next run, or fax it down to the pharmacy. Thinking of her patient, she faxes.

The pharmacist on duty in the Carnegie satellite pharmacy receives the order. He adds it to an already insurmountable tower of faxed and carbon orders. When he does eventually get to that order, he can’t read it. He pages the physician for clarification.

Because of the delay, the nurse calls the pharmacy to ask if they can expedite the order. The phone rings and rings as the nurse’s blood boils. What she doesn’t know: Four other nurses are trying to reach the pharmacist. And he’s busy getting clarification from the physician, at the same time he’s supposed to be signing off on the heap of filled prescriptions that need to go out on the next run.

Ok, so this is a worst-case scenario. But skillfully avoiding it puts a strain on both nurses and pharmacists. They work twice as hard to provide top-quality care and must rely on their creativity to navigate what’s become a clunky medication delivery model. And that’s why for several years, a core design team of physicians, nurses, pharmacists, patient safety experts—even two patients and a trustee—has been rethinking this model entirely.

The team is defining, from a whole system perspective, an ideal for delivering medication—one that makes the job of nurses and pharmacists better today, but is also forward-thinking enough to adapt over time. What they’re after is a system that combines automation, skills and training, plus the right attitude and culture, says Bob Feroli, medication safety officer and a member of the medication use redesign team’s steering committee. “With a more efficient and integrated system, providing safe care will be both easier and less stressful for our health care providers,” he explains.

The urgent nature of intensive care made the cardiac surgical intensive care unit (CSICU) and its step-down, the cardiac progressive care unit (CPCU), prime ground for piloting a system that promises to slash medication delivery time. The lessons learned there will factor into the physical design of the hospital’s new cardiovascular and critical care tower, and help fine-tune an ideal medication delivery program.

The CSICU and the CPCU have already significantly reduced the wait time on getting orders to the pharmacy and most of the illegibility problems, thanks to a system called PYXIS Connect. Nurses can now scan the original order and send a high-quality image of that order instantly to the pharmacy. On the pharmacy end, it organizes orders much like an e-mail inbox, listing the time each was sent and how long it’s been waiting for review.

PYXIS Connect is a key bridge technology during the roll-out of POE, the provider order entry system, which will eliminate the step of scanning paper orders. (Surgical units like the CSICU won’t roll out with POE until mid-2006.)

Also on all units are PYXIS Medstations, automated medication management systems that contain a small selection of frequently used drugs. PYXIS controls access to these via finger scan and password—and only those approved and remotely “unlocked” by a pharmacist.

This certainly helps, but these Medstations hold just a fraction of the medications nurses need at their fingertips. All others must be hand-delivered on the hourly runs, which contributes to a major job frustration of nurses and pharmacists alike: delayed availability of drugs on the nursing unit. “Medication must be given to patients in a timely manner,” says nurse clinician Marcia Bates. “With the current delivery system, that isn’t always possible.”

Faramarz Zarfeshanfard knows this all too well. The CSICU/CPCU’s point-of-care pharmacist says that when things get hopping around 4 p.m.—the hour that masses of operating room patients migrate to their floors—the machine that prints out the medication labels in the pharmacy goes haywire. The Carnegie pharmacy, for example, has so many orders to fill that the labels often curl from the printer all the way to the door, some 10 feet away.

The problem, says Zarfeshanfard, is the lack of staff (and space) to handle these requests, due to a nationwide shortage in the profession. “I wish pharmacists and nurses could trade places for a day so we could gain an appreciation for the pressure the other is under,” says Zarfeshanfard. “We all want to provide the best patient care possible and are forced to work in a way that doesn’t make it easy.”

But that’s about to change, starting with a massive expansion of the PYXIS set-up on the CSICU and the CPCU. Picture it: a double-wide, six-foot-tall tower filled with row after row of medication compartments—called CUBIEs, for computerized unit-based inventory exchange. The station is ever-filled with most of the medications the units require. Certain doses, such as individually drawn syringes, still need to be filled by the pharmacy.

Each CUBIE will contain one kind of medication—instead of each patient having a drawer with their own drugs. (This eliminates the possibility or even the need for frustrated nurses to “shop” for missing medications in other patients’ drawers.) PYXIS also tracks inventory and expiration dates, so when the supply runs low or gets too old, it sends a signal that instructs the pharmacy tech to make a refill run for that unit.

Frustration and waiting will be eased. The constant interruptions (translation: potential for error) will be tamed. Best of all, this model has the potential to shave medication wait time from more than two hours to as little as a few minutes. “It’s pared down to the essentials—writing the order, scanning the order, pharmacy review, and opening a compartment,” says Bates.

A former architect, Bates was tapped to team up with Zarfeshanfard and Facilities to redesign both units’ cramped medication rooms to create space for the expanded PYXIS Medstations. These configurations—especially that of the longer CPCU, which will have a station at each end—will help nail the physical requirements in the new adult tower. (Each of those huge, 32-bed units will be one and a half times the size of Nelson 4 and Meyer 9, currently the hospital’s longest.)

“If this system is proven to be safer, more efficient and more satisfying for nurses and pharmacists,” says Tina Cafeo, CSICU/CPCU nurse manager, “it makes sense to build it into the future of this hospital.”

-From Hopkins Nurse, Fall 2005

PHOTOS
MAIN: Marcia Bates, a nurse clinician on the cardiac SICU, and Faramarz Zarfeshanfard, the unit’s point-of-care pharmacist, pore over the plans for their expanded medication room.