Comprehensive Notes on Hospital Satellite Pharmacy Operations and Clinical Workflow

Overview of Pharmacy Satellite and IV Room Operations

• IV Room Characteristics:

  • The IV room is described as having a physical workload involving significant calculations.

  • Staff rotate in and out of the IV room and various satellite pharmacies to prevent stagnation, as the IV room can be perceived as tedious or "boring."

  • Technicians typically load medications in the IV room early in the morning ($06:00$ to $08:00$) and again around $12:00$.

• Satellite Pharmacy Definition:

  • Satellite pharmacies are described as the "retail version" of the hospital.

  • Primary responsibilities include receiving prescriptions, reviewing orders, and checking meds before they are sent to patient floors.

  • Specific to the 7th-floor satellite mentioned, it does not physically stock all drugs; instead, medications are dispensed directly to nurses or loaded into Omnicell machines.

• Centralization vs. Decentralization:

  • The speaker advocates for centralization for the sake of efficiency, particularly for order verification.

  • The current hospital model is decentralized, with pharmacies split across different units to serve specific patient populations.

  • Overnight operations are centralized in the HVN building, where a pharmacist verifies orders remotely for the entire hospital.

Physical Infrastructure and Unit Coverage

• Building Layout and Pharmacy Locations:

  • Main Building: Includes two satellite pharmacies (7th floor and 4th floor) and a pharmacist stationed at the 5th-floor nursing station.

  • HVN Building: Contains a main pharmacy on the bottom floor, an IV room pharmacist, and a 7th-floor satellite pharmacist. Clinical specialists round with medical teams here.

  • North Tower:

    • 10th Floor: Pediatrics (Peds).

    • 6th Floor: Adult Medical-Surgical (Med Surg).

    • 2nd Floor: Combination of Intensive Care Unit (ICU) and Intensive Care Nursery (ICN) pharmacists.

• 7th Floor Satellite Coverage (Monday–Friday):

  • 8th Floor (8 East): Adult Oncology unit focusing on solid tumors. There is no unit above the helipad, so only the East side is active.

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

  • 7th Floor East (7 East): Bone Marrow Outpatient Clinic.

• Turnaround Time Thresholds:

  • Inpatient Setting: Allowed $2$ to $3$ hours from order entry to delivery.

  • Outpatient Clinic: Must be delivered within $1$ hour to maintain chair turnover for scheduled appointments.

• Weekend Coverage Adjustments:

  • Staffing is consolidated on Saturday and Sunday.

  • The 7th-floor satellite takes over the 6th floor (Surgery units, including Orthopedics, Urology, and solid organ transplants like kidney, liver, and pancreas).

  • The 4th-floor satellite takes over the 5th floor.

  • "Hospitalist" patients (e.g., pneumonia or GI issues) are assigned to any open beds, often increasing complexity and workload.

Daily Operational Schedule and Staffing

• Pharmacist Shifts (Monday–Friday):

  • 7:00 AM Shift: Focuses on the general satellite work and the chemotherapy batch.

  • 8:00 AM Shift: Focuses on processing new chemotherapy orders.

  • 1:00 PM (Evening) Shift: Works until $21:00$ or $21:30$.

• The Chemotherapy Batch ($07:00$ to $08:00$):

  • This is an hour of uninterrupted time where pharmacists do not answer phones or process general orders.

  • Process: Reviewing chemotherapy cycles ordered on prior days (e.g., a 5-day cycle of Cyclophosphamide). The 8:00 AM pharmacist processes the first dose; subsequent doses are handled in the 7:00 AM batch.

  • Safety Controls: Labels for chemotherapy do not print automatically. The pharmacist must manually "force" the label out after confirming labs, patient stability, and timing. This is due to the high-risk nature of these drugs.

• Chemotherapy Audits:

  • Conducted after the batch is completed.

  • Involves tracking every chemotherapy dose to ensure it was administered or properly wasted. This prevents dangerous drugs from "floating" in the hospital system.

Clinical Verification and Electronic Health Record (Epic) Functions

• Epic Dashboard and Tools:

  • Displays pharmacy hours, label printers, and useful links (policies and procedures).

  • Includes a messaging system for administrators and medication messages for communicating with providers and nurses.

• Verification Queues:

  • Custom queues are created for specific units. Pharmacists use these to verify orders entered by doctors.

  • Examples of verified orders: Bowel prep ($250\,mg$ Neomycin), flushes for lines, and discontinued orders (e.g., stopping Lovenox if platelets fall below $50 \times 10^9/L$).

• Medication Reconciliation (MedRec):

  • Doctors often "release" home medication lists from outpatient records, which are frequently inaccurate or outdated (e.g., matching a March dispense date to current needs).

  • Errors caught in the transcript: Toprol XL vs. Lopressor, incorrect dosages for Gabapentin ($400\,mg$ TID vs. $300\,mg$), and Furosemide inaccuracies.

  • Interventions (iDents): Pharmacists document concerns in Epic to "cover" themselves in case of therapy delays and to communicate with MedRec pharmacists or technicians who interview patients to finalize the list.

Pharmacotherapy and Clinical Calculations

• Antibiotics and Dosing:

  • Rocephin (Ceftriaxone): Standard dosing is every $24$ hours. If a dose is placed $12$ hours after a previous one, the pharmacist evaluates if it's a one-time dose for discharge or a change in frequency.

• Insulin Management:

  • NovoLog Sliding Scale: Specifically used in patients who are NPO (nothing by mouth), often on tube feeds or Total Parenteral Nutrition (TPN). Checks are performed every $4$ hours.

  • Hardware: For inpatient use, pharmacists check for the existence of $3\,ml$ insulin pens in the patient's drawer before dispensing new ones to minimize waste.

• Heparin Infusion Protocol:

  • Range: $0$ to $30\,units/kg/hr$ IV continuous.

  • Weight Calculations: Actual body weight is used unless the patient exceeds $125\,kg$. In such cases, Adjusted Body Weight (ABW) is used with a $40\%$ correction factor.

  • Math Example:

    • Actual Weight: $149.7\,kg$; Ideal Body Weight (IBW): $68.5\,kg$.

    • $ABW = IBW + 0.4 \times (\text{Actual} - IBW)$

    • $ABW = 68.5 + 0.4 \times (149.7 - 68.5) = 101\,kg$.

  • Monitoring: Goal Anti-Xa level is $0.3$ to $0.7$. Levels are drawn every $6$ hours to adjust the rate. If the patient was recently on Apixaban, a "stat" Anti-Xa level is required immediately because Apixaban interferes with heparin monitoring.

• Electrolyte Replenishment:

  • Potassium Rule of Thumb: For every $10\,mEq$ of potassium administered, serum potassium typically increases by $0.1\,mmol/L$.

  • Example: Giving $40\,mEq$ should raise a level from $3.1\,mmol/L$ to $3.5\,mmol/L$.

Questions & Discussion

• Trainee Question: "When you're in the IV room, did you get a chance to follow the techs around to load medications?"

• Speaker Response: No, because the trainee was scheduled from $08:00$ to $12:00$, and the bulk of the loading/activity happens before or after that window.

• Trainee Question: "Is the weekend hit or miss?"

• Speaker Response: Yes, some weekends are busy due to surgery units (Orthopedics, Urology, Transplants) and hospitalist overflow, while others are quiet.

• Trainee Question: "What if the patient is a bit poor history?"

• Speaker Response: The MedRec pharmacists will call the outpatient pharmacy or the doctor's office to confirm the medication list.

• Trainee Question: "When you said if it's more than $125\,kg$, we use adjusted body weight, is it a Shands protocol?"

• Speaker Response: Yes, that is specific to the institution's protocol.

• Trainee Question: "Do you know where the restrooms are?"

• Speaker Response: There are employee-only restrooms at the end of the halls near the carts, and public/general restrooms through the main doors. There is also a nutrition room with water, crackers, and peanut butter nearby.

The full transcript of the operations regarding the IV Room and Satellite Pharmacy is in the provided notes. It includes detailed descriptions of IV room characteristics, pharmacy definitions, centralization versus decentralization, building layouts, daily operations, and clinical processes. If you're looking for specific sections within that, please specify, and I can provide summaries or excerpts.