Patient engagement and satisfaction at the forefront of regulatory initiatives.
Nurses and pharmacists are under increased pressure to spend more time at the bedside to deliver optimal care and outcomes.
At the same time, these healthcare providers must also work to as well as improve scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Success or failure in these areas can tie directly back to reimbursement and the bottom line.
A number of hospital medication distribution models exist that can optimize patient safety and maximize cost efficiencies.
As healthcare organizations work to improve care quality and lower costs, however, they must consider their own unique and complex nursing and pharmacy workflows and avoid taking a one-size-fits-all approach to medication distribution strategies.
Keep in mind that various medication management models offer different value drivers, so the ability to satisfy both nursing and pharmacy departments often requires an atmosphere of give and take.
The key to selecting the right model is assessing the unique workflows that exist within an organization, determining which model or combination of models is the best fit, and then committing fully to making that model a success.
However, regardless of the direction chosen, nurse leaders and the pharmacy department must work symbiotically to ensure the right medication management strategies are in place to reduce error, better manage inventory, improve efficiency and allow nurses to spend more time focused on patient care.
Pros & Cons of Two Popular Models
A technology foundation forms the core of two primary medication distribution models used in hospitals-cabinet-centered and centralized/patient-centered.
As both are embraced across the industry, it’s important to understand the pros and cons of each approach, as well as how technology impacts workflows and overall investment:
Workflows are managed with medication dispensing cabinets located on the nursing floors. It is important that enough real estate and equipment is available to adequately support this model.
A typical cabinet footprint utilized is a main and auxiliary cabinet for scheduled, narcotics, PRN medications and a Tower for IVs and bulk medications. This equipment holds approximately 80% of medications to be used for patients on the nursing unit. The remaining 20% patient specific medications are delivered to the nursing unit and can be placed in bins within the Tower, a refrigerator, some patient specific area or “loaded and unloaded” into cabinets throughout the day.
Pros: Cabinet-centered models optimize nursing patient care workflows by ensuring that medications are accessible and readily available to nurses on the unit. As cabinets are typically filled no more than twice a day, this model streamlines pharmacy workflows and maintains inventory.
Cons: While this model supports efficient pharmacy workflows, it can be labor intensive for nurses who must travel back and forth to cabinets to retrieve medications. The Institute of Safe Medication Practices (ISMP) guidelines recommend medication retrieval for only one patient at a time, so for nurses in the typical medical/surgical unit handling six patients, the time commitment associated with main medication passes three times a day can be significant.
Nurses may also encounter lines of other nurses at cabinets waiting to retrieve medications. This issue is more significant on units with higher nurse-to-patient ratios, such as med/surg or orthopedic units. For this reason, cabinet-centered models are often more productive for environments with lower nurse-to-patient ratios, great examples are labor and delivery, intensive care units (ICU) and the emergency department.
While cabinet-centered models give pharmacy more control of inventory, it is important to recognize a few items: increased equipment costs, increased inventory, the time required to optimize the medication cabinets and the financial implications of medications that reach their expiration dates while sitting in cabinets. These labor and financial implications must be evaluated carefully.
Centralized or Patient-Centered Models
Centralized or patient-centered models streamline nursing workflows and better support patient engagement strategies by enabling nurses to spend more time at the bedside.
This approach is characterized by 60% to 70% of medications delivered to specified areas (scheduled meds), while 30% to 40% of medications are available in cabinets (narcotics, PRNs, First Doses, IVs). Primarily, two versions of this model are seen today.
The first version consists of a workstation on wheels or computer on wheels (WOW/COW), in which a laptop is on the cart with locked medication cassettes. Each cart stays with the nurse throughout the day and is stocked with medications specific to the nurse’s patients.
Pros: This approach minimizes a nurse’s time spent away from patients retrieving medications. The technology is mobile, scheduled medications and supplies are together, there is a prep area available for the nurse and everything is at the bedside for safe administration.
Cons: Use of these workstations can become problematic, common complaints are weight of pushing the carts, thresholds, battery life and a CMS requirement that the technology needs to be in line of sight of the User. Another issue is nurses “borrow” medications from specific patient inventories for another patient and forget to replenish. When this situation occurs, it increases workloads for pharmacy staff trying to manage inventories. In addition, it can delay the administration of medications to patients whose medications were borrowed creating the dreaded “missing medication cycle.”
The second version entails medication servers which can be located inside or outside of each patient’s room. This model negates the need for heavy carts; nurses utilize “laptops on a stick” and prepare the meds on lightweight carts that offer a work surface or preferably, in-room computers with scanners.
Pros: Medication servers reduce lines associated with cabinet queuing and allow for a smaller cabinet footprint by eliminating the need for auxiliary cabinets. Borrowing of medications is greatly reduced and scheduled medications are close to the patient. Also, medications can be pulled out of the servers and sent with patients when transferred.
Cons: Stocking the scheduled medications in the Servers can be labor intensive for pharmacy-so a shared collaboration between the two disciplines is imperative. Workflow review for adherence is important in this model.
Some organizations have combined this server model with a pharmacy “concierge” model that assigns a pharmacy tech to manage approximately 80 nurse servers, with a direct phone number for nurses to reach the right tech if they need additional medications or answers to medication questions. This enhanced service helps streamline workflows for both nursing and pharmacy departments and greatly enhances patient care.
Choosing the Best Model
The best medication management strategies are seldom one-size-fits-all, even within a single hospital.
While a cabinet-centered/decentralized approach may work well for some facilities or departments, others may benefit from a centralized/patient-centered approach. In fact, some hospitals and health systems have found that a hybrid model combining components of the two approaches works best.
Although an organization may decide to use the cabinet-centered model in units with a low nurse-to-patient ratio, and a server or workstation model in other units, the key to successful implementation is the multi-disciplinary oversight of the medication management system as a whole. By establishing processes that ensure accurate inventory management and optimized staff efficiency for every unit, pharmacy and nursing together can provide the highest level of care to the patient and increase the reimbursements for their organization.
This fact can’t be overemphasized: Collaboration between nursing and pharmacy is critical to choosing a model that best supports medication management workflows.
Ensuring that a choice is made cooperatively and embraced by both departments starts at the top; the chief nursing officer must set the tone for collaboration by implementing a multi-disciplinary approach to medication management decisions. This can include establishing committee meetings to address communication challenges and help both nursing and pharmacy staff better understand medication management processes.
To create a win-win situation for all stakeholders, healthcare organizations must start with a medication distribution plan that proactively engages both nursing and pharmacy.
Michelle Murphy is a senior executive nurse consultant and Claudia Anderson is a senior executive customer success consultant at Aesynt.