In the National Health Service, automated medication dispensing is commonplace in many areas within hospitals. Implementing the technology in operating theatres, however, is far less widespread due to concerns over the ability to access high-risk critical medicines quickly during anesthesia.
The largest health organization in North Wales, Betsi Cadwaladr University Health Board (BCUHB) sought to incorporate automated dispensing throughout its full range of primary, community, mental health, and acute hospital services across six counties, in order to improve the security and accountability of medication use. Once enough experience was gained with the system, the decision was made to try it out within the operating theatre recovery area at Wrexham Maelor Hospital. Louise Howard-Baker, the Assistant Area Director for Pharmacy & Medicines Management for BCUHB spearheaded the project. She described the undertaking in the article titled “Automating Medication Storage in Theatres” in the April 2020 issue of the Clinical Services Journal.
In 2012, BCUHB contracted with TouchPoint Medical for 76 automated medication cabinets, installed across most acute wards, hospital admission areas, and critical care units. Manual storage cabinets are used differently in the operating theatre environment versus other clinical areas of the hospitals because immediate access to a variety of medicines is routinely essential. NHS guidelines state that medicines should be available in unlocked storage in certain situations. Automated systems can improve efficiency and safety, but also have the potential to delay the administration of medicines if access is impeded. Anecdotally, trials of similar automated systems in operating theatres have been abandoned due to these concerns. The project team proceeded cautiously.
Existing storage facilities and processes were such that each theatre suite had a central main medicine store within each of the recovery areas. These were regularly replenished manually by pharmacy staff. Storage in the recovery area provided medications for patients from five theatres that used the same recovery suite, with separate storage facilities in each of the five rooms adjacent to each theatre. Unlike all other storage in the hospital, these were managed by nursing staff, not pharmacy staff, who replenished the stock, as necessary. No records of any transactions were kept.
The storage system had been in place for many years and was recognized as being antiquated. It had also become common practice to leave cabinets open during surgery for easy access. Security was known to be compromised but was accepted as a necessary risk. TouchPoint Medical's engineers worked closely with nursing staff to ensure that the design met their needs. The company provided training for the intuitive and easy to use technology, but the team expected some resistance to change from staff members, nevertheless.
A decision was made to install the main repository system within the existing storage room adjacent to an eight-bed theatre recovery area. The main system was to be primarily designed to provide full product packs for the replenishment of medication for each of the five anesthetic rooms. A smaller unit was installed in the bedded area for access to medication needed during postoperative recovery. When the system was being configured, alerts designed by senior pharmacists were added to aid safer administration of medicines, and visual warnings were included.
After about 12 months of use, the team reported that the automated medication management system was well received by the users on the nursing and theatre management staff. Switching from manual processes was a heavy lift; however, most nursing staff enjoyed working with the systems, noted their ease of use, and recommended them over previous manual storage facilities. More than 90% of staff reported that biometric access to the storage systems provides them with “more secure” or “much more secure” access to medicines according to a survey.
Karen Pritchard, the patient safety pharmacist for the Maelor Hospital, commented: “A pre-requisite to the continued effective use of these systems is the quality assurance provided by pharmacy staff.” Designated pharmacy staff routinely review and correct stock discrepancies and picking reports are reviewed and reported to nursing management. Those staff who make picking errors are subject to further training and support.
The team notes that the key objective was to prove that automation could be safely applied to the theatre environment. This collaborative project took a cautious approach and revealed that the use of automation in this setting "has significantly improved the security and accountability of medication use in the operating theatre environment." David Bevan, the theatre manager, commented: “We had no benchmark in the UK, so we needed to prove the concept of automation in a theatre department would work. Our expectations have been met in that we have a system, which has been shown to be both safe and improves the security of medicines.”
Medication Inventory Control, Cost Savings
Full inventory control is currently in place, a function that was impossible with the manual system. Medicines are automatically ordered from the pharmacy store, which has resulted in a significant reduction in the number of additional emergency orders in between scheduled orders. Pharmacy and theatre managers are easily able to review the turnover of any products used for each theatre room and see who has ordered and accessed medicines. The project team has reviewed total theatre medication usage pre-and post-implementation and calculated the monthly expenditure for both main theatres. They found an immediate and sustained reduction in the monthly turnover of products and total monthly costs (see figure).
This pilot project has demonstrated the applicability, safety, and effectiveness of automating the storage of medicines in those NHS hospitals that currently utilize theatre recovery storage as the main storage repository for a theatre suite, Ms. Howard-Baker concluded.