Comprehensive Hospital Pharmacy Satellite Operations and Clinical Workflow

Overview of Hospital Pharmacy Structure and Satellite Locations

• Satellite Pharmacies vs. Main Pharmacy: The hospital utilizes a decentralized pharmacy model where staff rotate between the centralized IV room, satellites, and nursing stations. Although centralization is considered more efficient by some staff for order verification, the current model distributes workload across buildings.

• Building Locations and Layout:

  • 7th Floor Area: Contains two satellite pharmacies (one on the 7th floor and one on the 4th floor).

  • 5th Floor: Features a pharmacist integrated into the nursing station.

  • HVN Building:

    • Bottom Floor: Houses the Main Pharmacy and the IV Room pharmacy.

    • 7th Floor: Contains an HVN satellite pharmacy.

  • North Tower:

    • 10th Floor: Pediatric (Peds) satellite.

    • 6th Floor: Adult Medical-Surgical (med-surg) satellite.

    • 2nd Floor: Combined Intensive Care Unit (ICU) and Intensive Care Nursery (ICN) satellite pharmacy.

• Satellite Functions:

  • Satellites act as a "retail version of the hospital," focusing on receiving, reviewing, and checking prescriptions.

  • Medication dispensing varies; some satellites stock drugs which are then dispensed to nurses or loaded into Omnicell machines. Higher-floor satellites (like the 7th floor) may focus more on verification without direct drug dispensing.

Unit Coverage and Clinical Specialties

• Monday through Friday Coverage:

  • 8th Floor (8 East): Adult oncology unit focusing on solid tumors. Note: There is no unit on the west side of the 8th floor because it is located directly above the helipad.

  • 7th Floor West: Adult Bone Marrow Transplant (BMT) unit, handling hematologic (heme) malignancies such as leukemias, lymphomas, and myelomas.

  • 7th Floor East: Bone marrow outpatient clinic.

    • Clinic Differences: Outpatient units have much faster turnaround times. Orders must be processed within $1\,\text{hour}$ to facilitate "turning chairs over" (processing scheduled appointments), whereas inpatient turnaround allows for $2$ to $3\,\text{hours}$.

  • 5th and 6th Floors: Covered by the 5th-floor nursing station pharmacist.

• Weekend Coverage (Saturday and Sunday):

  • Staffing is consolidated on weekends. The 7th-floor satellite takes over coverage for the 6th, 7th, and 8th floors.

  • 6th Floor Specialties: Includes orthopedic surgery, urology, and solid organ transplants (kidney, liver, and pancreas).

  • Hospitalist Patients: General "overflow" patients (e.g., pneumonia, GI issues) are placed in open beds across these units when available. These patients are often more complicated and time-consuming due to multiple medications.

  • Weekend Split: While the 7th floor takes the 6th floor, the 4th-floor pharmacy covers the 5th floor.

Daily Workflow and Shift Responsibilities

• Staffing Tiers (Monday through Friday):

  • 07:00 Shift: General satellite work, routine orders, and the chemotherapy batch.

  • 08:00 Shift: Dedicated to chemotherapy orders.

  • 13:00 (Evening) Shift: Stays until $21:00$ or $21:30$.

  • Overnight: No pharmacists are physically in the satellites. Overnight verification is centralized in the HVN building and handled remotely.

• The Chemotherapy Batch (07:00–08:00):

  • This hour is reserved for uninterrupted work; staff do not answer phones or process new routine orders.

  • Definition: Processing chemotherapy orders placed in prior days (e.g., day 2 of a 5-day cycle).

  • Control Mechanism: Unlike other batches that print automatically, chemotherapy labels must be manually "forced" by a pharmacist after reviewing labs and patient stability to ensure safety.

  • Volume: The batch typically grows as the week progresses (Monday is smallest, Friday/weekend are largest).

• Chemotherapy Audits:

  • Performed daily to ensure all doses are accounted for (either administered or properly wasted) to prevent hazardous drugs from floating in the hospital unaccounted for.

Clinical Verification in Epic

• Pharmacist Dashboard: Contains links to pharmacy policies, resource summaries, label printers, and administrator messaging systems.

• Verification Queue: Filters orders by floor coverage. Pharmacists must verify new orders, modified orders, and discontinued (DC) orders.

• Custom Lists: Used to organzie tasks, including:

  • Vancomycin (PK) Consults: Managing pharmacokinetic dosing.

  • Renal List: Floors-by-floor check for patients requiring renal dose adjustments.

  • Duplicate PRN List: A regulatory/JCO requirement to ensure PRN (as needed) meds for the same indication (e.g., constipation meds like Colace and Senna) have specific sequencing instructions so nurses do not make autonomous clinical decisions.

• In Basket: A communication tool used for medication messages, such as missing doses, request for dosage form changes, or retiming doses (e.g., when an IV line "blows out" and a dose must be delayed).

Clinical Considerations and Medication-Specific Rules

• Anticoagulants:

  • Enoxaparin (Lovenox): Often held or discontinued if platelet counts fall below $50 \times 10^3\,\text{per microliter}$ or if procedures are scheduled.

  • Apixaban: Typical dose is $5\,\text{mg}$ BID, but is adjusted to $2.5\,\text{mg}$ BID for Atrial Fibrillation if the patient meets two of three criteria (age $\ge 80$, weight $\le 60\,\text{kg}$, or serum creatinine $\ge 1.5\,\text{mg/dL}$).

• Heparin Continuous Infusions:

  • Weight-Based Dosing: Uses actual body weight unless the patient exceeds $125\,\text{kg}$, then Adjusted Body Weight (AdjBW) is used with a $40\%$ ($0.4$) correction factor.

  • AdjBW Formula: $\text{IBW} + 0.4 \times (\text{Actual Weight} - \text{IBW})$.

  • Example Calculation: $\text{Actual} = 149.7\,\text{kg}$, $\text{IBW} = 68.5\,\text{kg}$.       $149.7 - 68.5 = 81.2$       $81.2 \times 0.4 = 32.48$       $32.48 + 68.5 = 100.98 \approx 101\,\text{kg}$.

  • Monitoring: Monitored via Anti-$X_a$ (unfractionated heparin) levels, calibrated specifically for heparin. Goal range for full intensity is typically $0.3$ to $0.7\,\text{units/mL}$.

  • Apixaban Conflict: If a patient was recently on Apixaban, the pharmacist must order a STAT Anti-$X_a$ level because the prior drug will artificially elevate the heparin monitoring results.

• Insulin and Blood Glucose:

  • Sliding Scale: Insulin (e.g., NovoLog) doses (e.g., $0$ to $7\,\text{units}$) are determined by blood glucose readings checked every $4\,\text{hours}$ for NPO (nothing by mouth) patients.

  • Standard Practice: For non-NPO patients, checks are usually done AC/HS (before meals and at bedtime).

• Electrolytes:

  • Potassium (K+): Rule of thumb is that every $10\,\text{mEq}$ of potassium given will increase serum potassium by approximately $0.1\,\text{mEq/L}$.

• Sleep Aids: Melatonin ($3\,\text{mg}$) is the first-line inpatient sleep agent, followed by trazodone. Zolpidem (Ambien) is rarely used unless it is a home medication.

Medication Reconciliation (MedRec) and iDent Documentation

• Medication Reconciliation: The process of correcting errors in the hospital's home medication list. Doctors often release home meds without verifying if the doses in Epic are current or correct.

• Common Errors: Incorrect strengths for Gabapentin, Keppra, or Lipitor often occur when intake staff select the first available option in the system.

• The MedRec Team: Pharmacists and technicians who interview patients and call community pharmacies/doctors to confirm exact regimens.

• iDent (Intervention): A documentation tool within Epic. Pharmacists use this to record clinical interventions, such as delaying an order due to dose concerns. This creates a "paper trail" to explain delays in therapy and protect the pharmacist in case of patient safety reports.

• Process: Pharmacists can attach a single intervention note to multiple medications simultaneously by adding the additional drugs in question to the existing intervention record.

Facility Resources

• Employee Restrooms: Located at the end of the halls near the delivery carts (access restricted to employees).

• Public Restrooms: Located through the doors near the satellite area.

• Nutrition Room: Contains a water dispenser, cups, crackers, and peanut butter for staff and clinical needs.