DRUG DISTRIBUTION METHODS Submitted By Jwala Mathew 4

DRUG DISTRIBUTION METHODS Submitted By: Jwala Mathew 4 th Pharm D.

INTRODUCTION : � It is one of the basic services provided by the hospital pharmacy department. � By this the pharmacist maintains a relation between physician, nurse and patient. � Pharmacy dept. distributes drugs to the patients through nursing stations or directly

DDS FALLS INTO THREE BROAD CATEGORIES: � Ward-controlled system (ward basket) where ward writes a order to pharmacy for all drugs it anticipates over a particular period time i. e. 3 -4 days or 7 days – pharmacy dispenses without seeing prescription. � Pharmacy controlled imprest-based system – commonly used -a defined range of drugs available in each ward and is managed by pharmacy staff. � Pharmacy controlled patient issue system – direct patient issue rather than the ward

DRUG DISTRIBUTION TO PATIENTS DRUG DISTRIBUTION TO OUT PATIENT (OP) � OP refers to patients not occupying beds in hospital. � Drug dispensing is through out patient department (OPD) � Patients with minor or common illnesses visit OPD and get medicines through prescription from pharmacy and take home these medicines.

TYPES OF OP: � Emergency OP - give emergency or accidental care for conditions require immediate medical attention. � Referred OP- referred directly to OPD by his/her attending physician for specific treatment (dental, ENT, ortho, etc. . ) � Primary care describes a range of services adequate for meeting the great majority of daily personal health needs; it includes the need for prevention, health maintenance and for evaluation and management of various symptoms, problems and chronic aspects of disease. � Ambulatory OP is able to walk and receive services without occupying bed, however majority of out patients are ambulatory.

LOCATION AND LAYOUT OF OP DISPENSING: There is no set rule regarding the location of OP dispensing area, preferably it should be located on the ground floor o f the building and near to the entrance, for easy access by the patients. � It should be close to the central registration and OPD, so that the patients do not find any difficulty in its location. ISSUE SYSTEM: � No medicament should issue without the prescription. After issue has been made the quantities supplied must be recorded in the issue register. A proper account must be maintained regarding the quantity received and issued. COST RECOVERY AND SERVICE CHARGES: � The price to be charged for filling the prescription should be reasonable, fair to the patient as well as to the pharmacist. The price should include the cost of ingredients, container, time required and reasonable margin of profit. �

Ideal layout of out patient dispensing

PRE-PACKING OF DRUGS IN HOSPITAL PHARMACY: � In hospital pharmacy concept of pre-packing is utilized in both the large and the small hospitals to fulfill the demand for pharmaceutical service. � In the small hospital pharmacist may prepackage only those items which he/she consider will require more time, if filled when called for at the time of dispensing. � In large hospitals it is economical to pre-package all ward stock items as well as the often prescribed tablets, capsules, syrups, ointments and creams used by both in-patients as well as out-patients clinics.

DRUG DISTRIBUTION TO IN PATIENT: � The drug distribution to the in-patient department (IPD) can be carried from the out patient dispensing area. � The staff handling the distribution of drugs to the out patients can carry out the distribution of drugs in in-patient department. � IPD can be located on the ground floor or first floor of the building but it should be near to OPD and centrally located so that the staff can easily reach there. � IPD is a multifunction department for storage, dispensing, manufacturing of i. v fluids etc. .

SYSTEMS FOR IN-PATIENT DRUG DISTRIBUTION DEPARTMENT: � Individual Prescription Order System � Complete Floor Stock System � Combination Of Both Two � Unit Dose Dispensing Method (UDD) � Non-Floor Stock System

INDIVIDUAL PRESCRIPTION ORDER SYSTEM: Rx for individual patient- drugs from any pharmacies— own charges � This system is used in small and/or private hospitals because of its economical considerations. � ADVANTAGES: All Rx are directly review by the pharmacist -less chances of errors � Provides closer liaison among pharmacist, physician, nurse and the patient in the medication matter � Provides clear control of inventory �

DIS-ADVANTAGES: Possible delay in obtaining the required medications for administration to the patient. � Increase in the cost to the patient �

COMPLETE FLOOR STOCK SYSTEM: Under this system the drugs the nursing station carries both charge and non charge medications, which are administered to the patients according to the medication chart/order of the physician. � Only the commonly used drugs in considerable quantities are stocked on the floor stock or in the ward. � Drugs on the nursing station or ward may be divided into : � Charge floor stock drugs – drugs which are charged to the patients accounts after they have been administered to the patients � Non-charge floor stock drug – drugs for which there is no direct charge to the patients account. In fact the cost of this group of drugs is usually calculated in the per day cost of the hospital room or ward.

ADVANTAGES: � The drugs are readily available for administration � Minimum return of drugs � Reduced in patient Rx orders � Reduction in the number of pharmacy personnel required DIS-ADVANTAGES: � Increase in chances of medication errors due to lack of review by pharmacists � Greater opportunity for misuse of drugs resulting in financial loss � Increase in drug inventory � Greater chances for pilferage � Drug deterioration problems due to lack of proper storage facilities and due to unnoticed drug degradation. � Greater load upon the nurse time

PRESCRIBING OF FLOOR STOCK DRUGS: Normally the orders are written in physicians own hand writing. There are three different types of procedures fallowed in dispatching drug order information from wards etc. to pharmacist. I. Schedule-X: Rx is written out on separate block by the treating doctor Carbon copy or other copy of chart order is sent to the pharmacist Chart order is transcribed by the person assigned to the ward II. Using a copy of doctors written order as a Rx order Pharmacist receives a copy of the original medication order No transcribing/copying is required Advantages: medication errors are reduced as pharmacist scrutinizes and reviews all drug orders III. Modified version of second system Physicians are permitted to mix all types of drug orders for a patient in a single sheet Advantages: pharmacist is provided with a whole picture of what is happening to patient

Sample prescription order Name of the patient ________ PHYSICIANS’S ORDER location wards x no. ______ Dr. ______________________________ Date ordered / Date discontinued orders ____________________ 27 -05 -2009 31 -05 -2009 Digoxin 0. 1 mg/one at 7 pm

In modern hospitals , a suitable copying machine (Xerox machine) is used to copy Rx. The drug requisition slip is then sent to pharmacy for reviewing and dispensing copied/transcribed drugs, which can be used by the pharmacist to create his “patient drug profile” which is of importance in monitoring and adding valuable information to the “drug information centre”. � It also contains the particulars of drug administration to the patient and particulars of ADR, side effects and interactions. In addition to this helps in initiating the medication charge. � LABELING OF FLOOR STOCK DRUGS: Packages containing non charge as well as charge floor stock drugs bear a label which shows the name and/number of the ward and the name and strength of the preparations as well as any other relevant information. � Floor stocked charge medication label contains patient’s name also. �

SELECTION AND DISPENSING OF CHARGE FLOOR STOCK DRUGS: � Selection of these drugs in various wards is decided by “The Pharmacy and Therapeutic Committee”. � Representatives of nursing service, pharmacy and administration should be consulted for guidance and advice. � Once the floor stock list is prepared, it becomes the responsibility of the hospital pharmacist to make the drugs available � Pharmacist should also re-submit the list to the pharmacy and therapeutic committee for reviewing and making any additions, deletions or alterations in the view of later experience and trends. � The list of drugs may vary from hospital to hospital. Further In the same hospital the suitability of the drugs to be procured for the floor stock system may change from time to time as per recommendations of pharmacy and therapeutics committee.

An envelope is used to dispense such drugs at nursing stations. � Under this system, pre-labeled envelopes are filled with pre determined quantity of drugs and are placed at the disposal of the nursing stations; and � When the drug is administered, the patient name and room number is entered on the envelope and sent to pharmacy for record and is forwarded to the accounts department. � List of drugs includes injections or other unit dosage forms: Anti allergics: Diphenhydramine Hcl inj. , Hydrocotisone sod. sucinate etc. . Antibiotics: procaine penicillin, streptomycin sulphate, etc. Anti coagulants: Heparin inj, LMWH etc. . .

SELECTION AND DISPENSING OF NONCHARGE FLOOR STOCK DRUGS: � � � For these drugs there shall be no direct charge from the patient’s account. Non-charge floor stock drugs consist of a pre determined list of medication available at every nursing unit of the hospital. The non-charge floor stock drugs are selected on the basis of cost of drugs, quantity required, frequency of use, and the effect on the hospital budget and reimbursement from third party payers(e. g. insurance). The list of drugs will vary from hospital to hospital, where such a list is exceptionally small and therefore, the patient receives bill for numerous single doses of drugs. This of course, produces bad effects on public relations and the pharmacist and the administrators should do all in their power to apply corrective measures to rectify the situation.

� � � DRUG BASKET METHOD is adopted where nurses check the medicines all rooms and in the refrigerator and prepare a master list for the pharmacy. Nurses fill a requisition form for delivery of drugs at their floor When there is an empty container, the nurse places it in the basket Once the procedure is completed the drug basket containing the empty containers and requisition for floor stock supplies is then sent to pharmacy Immediately in the morning the pharmacy staff commences to fill each container and dispenses the requested drugs; Once the basket completed it is delivered to the floor via messenger service; and

� Alternatively A MOBILE DISPENSER can be utilized: it is a specially constructed stainless steel truck measuring 60 inches high, 48 inches wide and 25 inches deep. It is mounted on bottom tiers, four of which are swivel type. � By using this system it will not be necessary for the night nurse to check the pharmacy inventory or have empty containers transported to the pharmacy. Instead the pharmacist or his assistants running the mobile unit will check the inventory of the ward or nursing station almirahs and off the items and quantity of supplies left. � The carbon copy of the requisition for floor stock supplies is left in the wards as a record of delivery and the original is returned to the pharmacy where it serve three purpose: To re-stock the mobile unit To determine the rate or use of consumption. To serve as a charge document for the internal allocation of costs

It has a number of advantages to the pharmacy, particularly if the truck is manned by a pharmacist. For instance, the drugs, in the nursing station drug cabinets will always be under the supervision of professional personnel. The availability of pharmacist for spot consultation by clinicians and nursing staff. � Further, through the routine checking of the medicine cabinets deteriorated or out-dated and non-approved drugs and samples may be quickly removed. � The list of Non-charge floor stock drugs includes fallowing drugs: Ampoules : Adrenaline 1 ml, Aminophylline 10 ml, Atropine Sulfate 25 ml, 2 ml, Digoxin 2 ml etc… � Capsules and Tablets: Aprin 150 mg, Paracetamol 500 mg, Dulcolax 5 mg, multivitamins, etc… � Solutions, Powders, Ointments, Creams, suppositories, etc… �

COMBINATION OF INDIVIDUAL PRESCRIPTION ORDER SYSTEM AND COMPLETE FLOOR STOCK SYSTEM: � This system uses individual prescriptions or medication order system as their primary means of dispensing but also utilizes a limited floor stock. � This combination system is probably the most commonly used in hospitals of our country today and is modified to include the use of unit medications.

UNIT DOSE DISPENSING METHOD (UDD) � Definition: those medications which are ordered, packaged, handled administered and charged in multiples of single dose units containing a predetermined amount of drug or supply sufficient of one regular dose, application or use. � In this system the multiples of single dose administration of medication are prepared by the pharmacist which are ready for administration to a particular patient by the prescribed route and the prescribed time rather than supplying containers of drugs to nursing units where the nurse is required to prepare the drug for administration. � A single unit package is one which contains one complete pharmaceutical dosage form i. e. one tablet, one capsule or 5 -10 ml oral liquid etc… � It is the responsibility of a pharmacist to institute this system in a hospital by forming a planning committee with the co-operation of nursing, administration and medical staff.

ADVANTAGES: � � � � � Patients receive improved services round the clock and are charged for only those doses which are administered to them. All doses of medications required at the nursing station are prepared by pharmacy thus allowing nurses more time for direct patient care Medication errors are decreased because of direct check by the pharmacist It eliminates labeling mistakes, excessive duplication of order and paper work at the nursing area and the pharmacy It eliminates contamination, wastages and pilferage of drugs More accurate charging eliminates revenue losses and credits It conserves space in nursing station and pharmacy by eliminating bulky stocks It extends pharmacy coverage and control through out the hospital from the time the physician write the order to the time patient receives the unit dose There is improvement in communication of medication orders and delivery systems

ADVANTAGES: � The pharmacist can get out of the pharmacy and to the wards where they can perform their intended function as drug consultants and help provide the team effort which is needed for better patient care � It can save time for both in pharmacy and on nursing service DISADVANTAGES: � It requires more space since packing material increases the bulk of the dosage form � It requires increased number of skilled and lay personnel in the pharmacy � The cost of medication is increased to the patient due to increased handling charges UNIT DOSE DISPENSING PROCEDURE: Two methods of dispensing unit doses are: � Centralize Unit Dose drug Distribution system (CUDD) � Decentralize Unit Dose drug Distribution system (DUDD)

CENTRALIZE UNIT DOSE DRUG DISTRIBUTION SYSTEM (CUDD): � All in patient drugs are dispensed in unit doses and all the drugs are stored in central area of the pharmacy and dispensed at the time the dose is due to be given to the patient � To operate system effectively, delivery devices such as medication carts and dumb waiters are needed to carry unit doses to the patients and also to send a copy of the physician’s original medication order to the pharmacy for direct interpretation and filling. DECENTRALIZE UNIT DOSE DRUG DISTRIBUTION SYSTEM (DUDD): � This operates through small satellite pharmacies located on each floor of the hospital � The main pharmacy is for procurement, storage, manufacturing and packing. It serves all the satellite pharmacies � This type of system is mainly used in hospitals with several buildings and old delivery systems �

The fallowing procedure is adopted in a hospital when a decentralize unit dose drug distribution system is adopted: Patient profile card containing full date, disease, diagnosis is prepared � Prescriptions are sent directly to the pharmacy which are the entered in the patient profile card � Pharmacists checks medication order for allergies, drug interactions, drug laboratory test- effects and the rationale of therapy � Dosage schedule is made and coordinated with nursing personnel � The pharmacy technician picks medication orders, placing drugs in bins of transfer cart as per dosage schedules � Medication cart is filed for particular dosage schedule delivery � Pharmacist then checks carts prior to its release � The nurses administers drugs and make the entry in their records � Upon return to the pharmacy, the cart is rechecked This process requires the availability of pharmacist for consultation by the doctors and nurses. In addition he/she maintains surveillance for discontinued orders. �

UNIT DOSE DRUG DISTRIBUTION CAN BE ACCOMPLISHED IN A NUMBER OF WAYS: The first method is through the use of strip packaging and vial and syringe filling equipment in the hospital. � The second method is service from an outside contractor or by the joint purchase and sharing equipment with a nearby hospital. � The third method is to purchase all drugs in unit dose packages. Since the cost of production of unit dose packages is very high and the type of patients coming to general hospitals is usually poor, this method Is not popular in India. �

Dispensing of charge non-floor stock drugs: � � � Charge plate method is adopted by the hospitals to identify the patients. In this a plastic or metal card is prepared on the admission of patient to the hospital-nursing time is saved Accordingly all charge stations are equipped for using this time saving devices The order forms are prepared I triplicate, one is for pharmacy, one for accounts department and a control copy for the ward Pharmacists prepare periodic charges to the patient’s account and restock the ward with the items consumed

Pharmacy charge non floor stock requisition form Pharmacy no_____ INDOOR -private -semi private -ward private Request for OUT DOOR -clinic -emergency -private -ambulatory Patient’s Name________ Number ___________ Area and Floor ________ Requested Dr. ________ Date ____________ Cost Unit Charge Total Cost Total Units Total Charge

Reference: � A Text Book of Hospital Pharmacy by Dr. J. S. Quadry, 10 th edition, B. S. Shah Prakashan publications, page no. 109 -122 � A Text Book of Hospital and Clinical Pharmacy by Prathibhanandh, 1 st edition, Birla Publications, page no. 53 -69