Chapter 13
Interpretation of the Hospital Drug Order
We have already looked at the interpretation process involved in filling retail prescriptions. Now we will turn to the process as it exists in hospitals.
The Hospital Method
The hospital process is quite different, and we must first get a feeling for the overall drug distribution process involved. As you have seen, the record of drug orders is known as the MAR. Any medications the patient is currently taking, or has taken during this hospital stay will appear on the MARs. The medications are written by the patient's nurse and as doses are given, they are logged on the sheet. Each dose has a notation of time given and the initials of the individual who administered it.
When additional medications are ordered, a copy of the MAR is made and forwarded to the pharmacy. The pharmacist will then determine the completeness and appropriateness of the order. If it passes inspection by the pharmacist, the medication will be sent to the nurse for administration.
Drug products may be stored for use in several places. Commonly used large volume intravenous solutions, which do not require additional drugs be added to them, are usually stored at the nursing station med room. These medications are generally known as floor stock. Depending on the area and medical specialty involved, other medications may also be stored in this way. When dealing with floor stock, one thing must always be remembered. It is the pharmacy who is responsible to see that the medications are stored and used properly, and it is the pharmacy who decides what medications will be stored there.
Medications which are commonly used during life threatening emergencies need to be available to the practitioner without delay. These medications are kept close at hand on each nursing area in containers known as crash carts or emergency trays. As with floor stock, these medications are the responsibility of the pharmacy. This group of medications bring up an interesting point on the MAR and pharmacy review. There are times when a dose of medication will be given before the pharmacist can review the order. An emergency drug is a perfect example of this. In this situation, the pharmacist will receive the MAR with the notation of administration already present, and the pharmacist will conduct a retrospective review (meaning after the fact) of the medication use. While retrospectively reviewing a medication use won't do any good for this patient, the findings can help future patients. Any incorrect usage of the medicine can be covered with the practitioner, and future patients will benefit.
Intravenous products into which the practitioner wants additional medication added are handled by the IV Admixture area of the pharmacy. These workers are skilled in the specialty area of IV fluids, their use, and their compatibilities. Work performed in this area must adhere to stick sterility standards which we will discuss in a future chapter. MARs which have orders for these products will be routed here. The scheduled times for administration are taken into account, and the product is prepared for delivery to the nursing unit close to the time at which it is needed.
Medications which are to be given on a repeated basis, and are available in a unit dose package, will be handled through the inpatient pharmacy via the cart exchange process. In this process, medications which a patient will use for a specific time period (usually 24 hours) will be placed in a bin marked with their name and location. This bin is then placed within a cart which holds bins for all of the patients on that nursing area. Each day at the appointed time, this cart is then switched with the cart from the previous day, giving another complete day's supply of medication for the patient.
This system works well, but what happens when the practitioner writes a new order during the day? When this occurs, an amount needed to supplement the current cart in use is sent to the floor in a container marked with the patient's name and location, and the following days doses are added to the new cart being filled for the next day.
Controlled Substances are also handled differently. Controlled substances which are often used, such as pain or sleep medications, are floor stocked on the nursing unit. They are stored in a separate, lockable, storage facility on the area. At the start of each shift these controlled substances are inventoried by the nurse responsible for them during that shift. This count is then recorded on a perpetual inventory sheet. As a dose is used from the stock, it is signed out on the inventory sheet. This way, at any time, a person should know exactly how many doses are present in the lock box by reviewing the perpetual inventory. Controlled substances may also be stored in the main pharmacy. These would then be signed out on a dose by dose basis. When replacement medication is needed, it is ordered by the nurse in charge, signed out of the pharmacy by the pharmacist, and then signed for by the nurse when received and placed into the inventory.
Some hospitals have their own version of a retail pharmacy, known as the outpatient pharmacy. This area functions identically to a retail pharmacy in the community, and is subject to all the same regulations and procedures as their retail brothers. This area of the pharmacy requires its own licensure and inventory. Inpatient and outpatient pharmacy inventories should not be mixed. The outpatient pharmacy does not generally serve the community at large. Their patrons tend to be employees of the hospital and discharge prescriptions for patients leaving the hospital.
Abbreviations
The hospital MAR will contain the same abbreviations we have discussed for retail pharmacy. Remember what we have already stated about MARs. Orders on the MAR are always written by time schedules, not number of times per day. What happens if a practitioner forgets and writes TID instead of times? The pharmacy policy will contain a statement as to how the general term TID will be interpreted. It may define TID as being given at 7am, 2pm, 6pm. Then if the doctor writes TID, the person transcribing the MAR will automatically transfer the stated policy schedule onto the sheet. The MAR will still reflect exact times.
Prescription Date (D/C times)
Pharmacy policy will also dictate how long a written order will be filled without an order to continue. Usually, legend drugs will continue until such time the practitioner writes an order to stop the medication (a D/C order). Controlled drugs are usually good for a set period of time (ie, 3 days). At the end of that time period the medication will cease to be given unless the practitioner writes an order to continue the drug. You can see that an MAR will not contain a number of "refills" to be given. It will be governed by the time limits imposed by pharmacy policy.
Bulk Drugs
Some medications do not lend themselves to unit dosing. For instance, it would be impossible to unit dose eye drops. It would also be equally futile to try and unit dose a cream or ointment. This problem is solved by the concept of bulk drug dispensing. The term bulk refers to the fact that many doses of the product will be in each container, as opposed to a unit dose package which contains just one dose. When a bulk drug is ordered, the appropriate package size is chosen, labeled with the patient's name and location, and sent to the nursing station. The nurse then places the bulk medication in the patient's bin in the medication cart. When the next cart exchange occurs, the pharmacy technician will transfer the bulk drug from the patient's old bin to the new one. The bulk drug does not return to the pharmacy until that patient leaves the hospital. If the bulk drug is completely used, a new package is ordered from the pharmacy on the MAR. A new package is not routinely sent to the floor. It must be reordered.
Calculating the Quantity to be Dispensed
When calculating the amount to be dispensed, the most critical factor to not is the time at which the cart exchange takes place. When a new order comes to the pharmacy, the number of doses which will occur before the cart exchange must be sent directly to the floor. The number of doses which are required to complete the next cart exchange period are then place into the patient's bin in the next cart.
Let's say it is now 6 am. Our cart exchange occurs at 11am. The floor sends down an order for Amoxil 500mg caps po at 7am, 2pm, and 8pm. Ask yourself, how many doses must be given before our next cart gets to the floor? In this case, one. The 7am dose must be given before our cart goes to the floor. We would send one 500mg Amoxil capsule to the floor as soon as possible to account for the 7am dose. You then should ask yourself, how many will be required to complete the next cart period? (let's say we're on a 24 hour exchange) In this case, until the drug is discontinued, we would need to place three 500mg Amoxil capsules in the patient's bin contained in the next cart to go out.
The Formulary
Simply stated, a formulary is a list of the medications that the pharmacy normally stocks. It isn't possible to carry every medication within any given pharmacological class. Both financial and space problems make it impractical. What must occur is a decision of which items within that class will be stocked. How is the decision made? Factors such as drug cost, drug effectiveness, the frequency of need, storage requirements, and adverse effects are considered. If we have two drugs, Drug A and Drug B, which both have the same effectiveness and side effects, but Drug A costs 30% less than Drug B, which do you think we should stock? While this is an over simplified example, decisions like this are made in pharmacies every day.
Normally, a committee within the hospital is formed to create and manage the formulary. This committee is often known as the Pharmacy and Therapeutics Committee. It is made up of the pharmacist and members of the professional community within the hospital. Medicine, Nursing, and Dietary are often represented.
The objective of the P & T committee is to create a list of needed medications without stocking unnecessary or duplicate drugs. In the event a non-formulary drug is needed, a specific course of action is dictated for the practitioner to obtain approval for the temporary acquisition of the medication. If there is enough need, the committee will consider adding it to the formulary.
Changes to a formulary a routine. New drugs may come out. Patient needs may change. Updated information on old drugs may come out. Change is necessary.
Computerized Medication Access Systems
A fairly new concept in medication delivery is making it's way to the nursing stations. Computerized systems for storing and dispensing medications is replacing common drugs in the cart exchange system. In systems, such as the PYXIS Medstation™ system, common medications are stored in a computer controlled box much like the candy vending machine we all loved as kids. The operator keys in the needed medicine and the patient it is to be used on. If the information matches what is in the pharmacy computer, the unit dosed medication is dispensed to the operator. Individual access passwords for the operators insure only authorized access may occur. Also, through the password process, we know exactly who withdrew each dose and for what reason.
The pharmacy department is responsible for periodically replenishing the medication, as they do for floor stocked items.
Only the most common medications can be dispensed in this manner, and a supplemental cart exchange must still take place for items not contained in the dispensing unit. This method does have the advantages of access to drugs for the nursing staff even if the pharmacy area of the hospital is closed for the evening, and less time spent with cart fill and cart checks for the pharmacy crew.