January 2013 is the current Centers for Medicare and Medicaid Services (CMS) deadline for long-term care pharmacies to dispense brand-name oral solids in supplies of 14 days or less. One such facility has already made the move, with surprisingly positive results.
HarmarVillage Care Center (HVCC), a 130-bed facility located in Cheswick, Pa., is part of the Grane Healthcare family of skilled-nursing facilities. Grane, with offices 10 miles away in Pittsburgh, also provides pharmacy services to those facilities.
Seeking the Best Solution
HVCC’s chief administrator, Greg Hall, says they started considering the change — along with a move to automated tablet packaging — almost three years ago.
According to Hall, the problem with 30-day supplies is that orders change or are discontinued, or residents are discharged from the facility entirely, often well before a month’s supply of medication is exhausted. Unused drugs were returned to the pharmacy and disposed of.
“We felt by going to a seven-day supply, or even better, a four/three-day supply twice weekly, we could significantly reduce waste,” Hall says.
In addition to the cost of the wasted drug, Hall’s nursing director Linda Imm says, 30-day supplies also made her staff less productive.
“We spent a lot of time documenting the return of drugs to the pharmacy for proper disposal,” Imm says. “Also, if a resident was moved temporarily to the hospital, we’d have to document what cards we had on hand and how many, so that when the patient returned, the pharmacy wouldn’t ship us those meds all over again. It was very time-consuming.”
Other equally important issues that Hall and Imm sought to address were the drawbacks and inefficiencies inherent in the use of bingo cards. The cards are bulky, and the nurses’ medication carts had become cluttered and disorganized.
“With 20 residents per cart, and many on four or more meds, the drawers quickly became so full you couldn’t fit another card in,” Imm says. “If the cards got out of sequence, it took time to hunt down the resident’s medication. Sometimes pills would simply pop out of their plastic cells and fall to the bottom of the cart. Cleaning the carts and keeping them organized became a real issue. With pouch packaging we knew we’d be much more organized and efficient in distributing meds.”
Over the next few months, pharmacy and nursing home staff met regularly to thoroughly review the pluses and minuses of moving to a shorter dispense cycle and pouch packaging. Other facilities that had already made the same changes were visited. In June 2010 the team decided to implement short-cycle pouch packaging at all 12 Grane facilities, with HVCC as the beta site.
Belinda Burchick, Grane’s pharmacy informatics director, says that’s when the real work began.
“We intentionally took a slow, methodical approach to the project,” Burchick says. “There’s considerable impact on the organization from a process-flow standpoint when converting from bingo cards to pouches, and we wanted to make sure we got it right the first time.”
A project team with representation from both pharmacy and the facility was formed. Burchick says involvement from all stakeholders was critical to the project’s success.
“We knew preparation and planning would be key,” she says. “Pharmacy couldn’t make it happen alone, nor could nursing. It took both sides working together to ensure success.”
Study Findings Validate Productivity Improvements
Jae Chung is a pharmacy consultant with TCGRx. Chung conducted a study at HVCC comparing nurse med pass productivity before and after the conversion to pouch packaging and the shorter dispense cycle. Chung cautions that the study was for one home only, with a specific workflow environment, and isn’t necessarily representative of the overall market. But his findings clearly suggest there was noticeable improvement at HVCC.
Nurses spent nearly 70% of their time reviewing the MAR, unlocking/locking the cart, getting and preparing the meds, walking back and forth to the resident, administering the meds, and updating the MAR (see figure 1). Less than 10% of their time was spent actually assisting or treating the resident.
Chung’s study measured the impact on pass times of using 30-day bingo cards versus a four/three weekly dispense cycle and MD strip-based pouch packaging (see figure 2). Savings amounted to about 50 seconds per patient interaction. The savings can be significant considering the many times per day nurses engage in this activity.
There was also a 10.4% reduction in the amount of time required to pass the meds using multidose pouches versus bingo cards. For six nurses serving 120 residents, total labor cost savings for the three shifts combined: 3.99 hours.
“Grane had a decided advantage in that they own both the pharmacy and nursing operations for their facilities,” Chung points out. “Any pharmacy operation seeking similar success would do well to promote the benefits of converting to short-cycle dispensing and pouch packaging to their prospective LTC clients just as Grane did.”
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Goals and Issues
Hall says the team focused on five broad project goals:
- Seamless transition with no medication errors.
- Full compliance with all DEA medication administration rules.
- Waste reduction.
- Nurse acceptance.
- Reduction in medication deliveries from twice a day to once daily.
“We’re responsible for the health and welfare of our residents,” Hall says, “so we couldn’t afford any blunders.”
In the spring of 2010 Grane’s pharmacy had implemented the Beacon “pick to light” inventory management system from TCGRx, the first LTC pharmacy to do so. Shortly afterward they added an automated tablet packager (ATP) from the same company to support the pouch packaging initiative.
There was discussion early on about whether to put the ATP at the pharmacy or at the facility, but it quickly became clear that having it at the pharmacy made the most sense. Primary concerns, according to Imm, were the amount of time that running the equipment would take away from other nursing duties, the fact that they’d need to train staff on how to operate the technology, and the lack of space at the facility for the equipment itself.
“I was also uncomfortable storing so many more drugs at the facility than we currently do, and concerned about how we would get our meds if the equipment went down,” Imm says.
With the right technology in place at the pharmacy, the team started working through the many issues that had to be addressed before they could go live.
How many days’ supply would they now dispense for residents, and on what schedule?
The team decided to go with a four/three dispense cycle, with deliveries on Sundays and Thursdays. They felt this allowed the most flexibility in responding to changing drug orders, while keeping waste to an absolute minimum.
How many tablets would go into each pouch, and how would the pouches be sequenced?
Medication pouches — each containing no more than three orders per patient and a maximum of about 10 total oral solids — would be produced by the ATP at the pharmacy in spools by nursing station (cart). Within each nursing station run, pouches would be sequenced by patient and, within patient, by administration time. The ATP would print a header and footer for each resident so nurses could easily separate the meds by patient.
How would the pouches be stored in the carts, and would the carts have to be modified or replaced? What about routine meds versus PRNs?
“Our six carts were relatively new, so instead of replacing them, we modified them in-house,” Imm explains. “The drawers now contain two small blue bins for each resident: one for routine meds, another for PRNs. The bins keep the oral meds separate from the ointments, creams, inhalers, etc., and there’s plenty of space in the cart for other necessary supplies. Everything is neat and organized.”
What information would be printed on each pouch?
Imm says, “We started by making sure that everything that was legally required was there, then we went to our wish list of important things like ‘Do not crush’ or ‘Give this med only at a certain time.’ We ended up with a label that works very well for us.”
How would discontinued orders be handled?
Imm explains the creative solution they came up with: “Let’s say a resident is on 20 mg Lasix and that medication is delivered in a pouch with two other meds. If the doctor discontinues the Lasix, the nurse pulls out that resident’s bin, uses a yellow highlighter to mark the Lasix on the three or four pouches that may be inside, and writes ‘DC’ for discontinued. Then, a staple is used to physically separate the Lasix from the other pills in the pouches so that when the pouches are opened, only the doses that haven’t been DC’d fall out.”
How would narcotics and other drugs requiring extra care be handled?
For more control, it was decided to continue packaging narcotics in bingo cards. The cards are stored in a separate, lockable compartment in one of the cart’s drawers. Other drugs requiring special handling, such as Coumadin and chemo drugs, are set up to be packaged separately in their own pouches.
Nurse Acceptance: A Key Success Factor
One of the team’s primary concerns was buy-in from the nursing staff.
“Nobody likes change,” Burchick points out. “At first, the nurses were a little apprehensive about the new technology and process. HVCC was the first — no one else at Grane was using pouches or four/three dispensing, and they didn’t know what to expect.”
The goal was never to save enough nurse time to cut back on nurses’ hours or reduce head count, Imm says, and it was important for staff to know that.
“It was all about redirecting unproductive time to more value-added, patient-focused areas,” Imm says, “with the overall goal of improving the quality of clinical care provided. We were crystal clear with the staff about this from the beginning, so there were no misunderstandings about what we were trying to accomplish. The nurses saw we were trying to improve their work lives, so we had solid buy-in from day one.”
As preparation continued, the team decided to take a 20-bed wing of the facility live on the new system in midOctober. Last-minute details like how nurses would crush meds were worked through.
“The pharmacy provided us with test meds in pouches,” Imm says, “and we were able to crush the tablets right in the pouch — this was a big time-saver for us that we hadn’t expected.”
Countdown to Go-Live
One month before go-live, they began a “medication countdown” process in which the day’s supply delivered in a resident’s card was reduced to reflect the amount of time until the go-live date (i.e., 25 days’ supply 25 days out, 15 days’ supply 15 days out, etc.).
“This way we weren’t stuck holding weeks’ worth of medication for a resident when we switched to the shorter cycle,” Imm explains.
Imm says that, as part of nurse training, the pharmacy provided sample pouches with meds in them. “We were able to play with them and become comfortable with how to open and handle them. The edges are serrated, so they’re very easy to open,” she says.
Both pharmacy and nursing home staff gathered at the facility the night before go-live for the initial delivery of pouches. Medication carts were modified by HVCC staff during the overnight hours; Imm says that loading the pouches into the modified carts was a breeze.
“It took me about eight minutes to remove the spool of pouches from the box it came in, separate the pouches by patient, and place them in the bins in the cart,” Imm says.
There were some initial problems, Imm says, with pouches missing some meds and unexpected issues like how to deal with transferred patients. Each nurse kept a discrepancy log to track the shortages and other bugs, a tool they still use today, although much less frequently. Imm says that in all cases pharmacy or IT staff was quick to address the problems.
As the pilot continued, staff spent time creating index cards for the 220 medication bins they needed to take the rest of the facility live — two for each of 110 residents — and the rest of HVCC’s med carts were modified. Grane took the rest of HVCC live on the new packaging and dispense cycle on Oct. 24, 2010, and rolled the system out to its remaining 12 facilities over the next nine months.
Measuring Project Success
“All defined success metrics were solidly met,” Hall says. “And while it’s hard to determine the exact amount of savings from reducing the amount of wasted medication, when we compare what we’re disposing of now to what we were throwing away with 30-day supplies, it’s obvious to us that waste has been greatly reduced.”
Burchick says that, in her eyes, nurse response validated the project’s success.
“Ten days after we went live,” she explains, “we did a customer survey to get a feel for what the nurses thought. The feedback was extremely positive across the board. This process has repeated itself at every facility we’ve converted.”
And Imm couldn’t be more pleased. “Overall, despite the initial discrepancies, the conversion process was very smooth,” she says. “With all the planning it was a nobrainer — it just happened. We really feel like we received the benefits from it we were expecting: reduction of medication waste and better use of nurse time.”
Imm points out that, start to finish, nurses are spending basically the same amount of time as before distributing meds. What she’s noticed, though, is that nurses spend noticeably more time interacting with residents.
“There’s a focus on getting the meds delivered first and foremost,” she says, “and with the old system, that took more time to do. We definitely have more quality time now to spend with residents, to do better patient assessments, and that translates to improved patient care.” CT
After spending over 20 years as a sales and marketing professional in the pharmacy automation industry, John Becker is now a freelance writer and consultant based in Atlanta. He can be reached at jnbecker@me.com.