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Pharmacy: Distribution and tarification of painkillers: a practical approach Claudine Ligneel Hospital pharmacist Pain control at the OT Narcotics in (tool)boxes In UZ Brussel since 2008 Narcotic box 2 boxes with same content for each anaesthesiologist or resident Narcotic box Boxes are locked with 2 padlocks (secret code allocated by pharmacist) Narcotic box 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 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 Repleting of narcotics is controlled by a pharmacist and boxes are returned to OT next day Narcotic box 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 medication in 2 reanimation trolleys in the medication room at OT Pain control at the OT 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 Anaesthesiologist ticks used medication on preprinted activity sheet Other painkillers in trolleys Tarification at OT through scanning patients’ barcode and barcodes of used medication Other painkillers in trolleys Picking list of used medication Pain control at the OT Medication repleted in the medication cabinet, locked with secret code Pain control at the PACU Automated Dispensing System (Vanas) login with fingerprint Automated Dispensing System (Vanas) 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) 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) Next working day a picking list is printed in the pharmacy Automated Dispensing System (Vanas) 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 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 Link with logistic system automated control of stocks (ERP) Link with tarification system (UZB APB) Pain control starting at the PACU 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 PCIA PCEA PCPA/Elastomere pump (CPNB = continuous perifere nerve block) Patient Controlled Anesthesia Pain control starting at the PACU 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 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 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 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 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 CIVA = Central IntraVenous Admixture Pharmacy study for CIVA - PRO 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 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 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 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 44 PUO 14-12-2010 Voorbeeld 45 PUO 14-12-2010 Voorbeeld Medication selection On Hospital Formulary List 46 PUO 14-12-2010 Voorbeeld Information at moment of prescribing 47 PUO 14-12-2010 Pain control on the wards 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 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 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 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 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 Automated Dispensing System (Vanas) Implemented since 21 May 2013 810 references Narcotics not yet included 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