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Posts: 81
Registered: ‎04-05-2010
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Efficient Workflow in a CAI/CACI

We don't want to have a crowded isolator and we don't want to mix patient orders in the isolator.  Bags aren't labeled until completed and out of the isolator so we have tend to complete one or two orders before having to pull our arms out to remove and label the completed CSPs and refill the transfer chamber with more work orders. A tech is in and out and in and out of the isolator many times during a shift and that is mostly wasted time that we didn't have with Laminar Airflow Hood.  We could move product in and out of them relatively quickly and complete a lot more admixtures per unit of time than we now can with the isolators.  I would like to know how some of you have made this work process more efficient.  Do you work on CSPs for only one patient at a time which might include a 3 or four LVPs with KCL and 2 different IVPB antibiotics of 2 or 3 doses each or do you make a lot of D5W w/ 30 of KCL for many patients at a time.  How do you arrange your supplies and get them in and the completed CSPs out of the isolator as efficiently as practical.  Do you setup all of your IV orders in bins so that you have all of the supplies and labels needed for a particular patient?  Do you label the product inside or outside of the isolator (I believe USP 797 doesn't allow the labels inside the isolator.  And if labels aren't supposed to go inside the isolator and a CSP is not labeled until it is completed, how do you label chemo?  You can't label it in the isolator and you have to have it in a ziplock bag when it is removed from the isolator.  If you open the bag to label it you have defeated the purpose for the bag.  Do you just label the ziplock meaning the IV will hang without a label because the chemo ziplock bag is disposed of when the CSP is hung? 

 

As I make our techs comply more fully with USP 797 it seems like they become less efficient and we have problems doing the volume of work we have in the amount of time allotted.  We aren't going to get more IV techs and we can't limit the number of CSPs we are willing to make in a shift (maybe there's a union out there somewhere that could do so!).  On real busy days, which are common, we stay behind all day with nurses complaining about late IVs.  This tends to put everyone on edge and it makes for a very unpleasant day.  No one wants to make IVs anymore.  They complain if they have to spend more time in the cleanroom than another tech does.  You have to make sure they aren't developing bad habits and shortcuts to speed up the work.  Adding additional personnel is not possible.  I have to find another way to get the work out faster.  I would appreciate any suggestions or ideas.

 

Thanks,

 

Robert Martin, PharmD

Nacogdoches TX

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Posts: 61
Registered: ‎05-18-2011
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Re: Efficient Workflow in a CAI/CACI

This definitely an issue and at a higher volume hospital I am not sure how it works efficiently. I can explain how we do things but our hospital size is about 140 beds so I don't know if this is comparable. I also am not sure if you already do this so pardon if I am restating the obvious to you. We realized significant work flow issues when we first moved to the CAI and recognized that we had to do things differently. At this time, we were supply a 24 hour IV med cart exchange and delivering this at approx 1400 each day. The only meds that we compounded on evening and nights were new starts, and on demand ICU drips, etc. Our IV label batch run runs around 0830. This was not working too good and there was too much being compounded between 0830 and 1400 when we delivered - not efficient. Over time, we determined our frequently used antibiotics that we need to compound and determined par levels that have on hand at all times. We also started using more frozen, and premixed IV antibiotics, premixed electrolytes etc. We also now have an IV compounded mix our TPN's.

 

Now, we still do our IV cart between 0830 (IV label run) and 1400 (delivery time) for our 24 hour exchange, however, we are have tried to make it mostly a pull and label function, obviously not completely . We still need to compound stats, ICU drips, etc.  We batch compound items such as Met-cef, Azithromycin, PCN - for example, which are frequently used items that we do not have available to us other than being compounded by pharmacy and set par levels of these to have on hand at all times. Essentially, we pull our IV cart from items we keep in stock and then the tech is free to compound Stats and misc compounded items as needed and each shift is responsible for keeping the par levels of our batched compounds on hand at all times. Restocking of par levels can be done as the tech has time throughout the shift. We figured out these par levels based on average monthly usages and expiration dating. We have tracked waste monthly as well to ensure that we are not batching too much and wasting. For our volume, this system seems to work well and keeps the CAI fairly open for those items needing  to be compounded. For items that are only stable for 24 hours or for those items that are expensive (ex: daptomycin) or may be changing doses, we set up a system that these items are compounded over the 3 shifts. For example, items that fall into the above mentioned categories, we mix doses from 1401-2400 on day shift, for doses due between 0001 and 0700, evening shift will mix, and for doses from 0701-1400, night shift will mix. In this fashion, we evenly split the workload and try to minimize waste by not mixing 24 hours worth all during our day shift, again freeing up the CAI during day shift hours. I hope this makes sense to you. LEt me know if you have questions or do not understand what I mean and I hope it helps (and I don't sound silly)Smiley Happy

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Registered: ‎04-05-2010
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Re: Efficient Workflow in a CAI/CACI

Thanks Pattik,

 

Your "before" situation sounds a like like ours.  We are 125 beds but open only from 7AM - 9PM.  A sister Tenent hospital takes over remotely from 9PM - 7AM just for entering orders so nurses can keep emars up-to-date and get meds from Pyxis.  We start making IVs around 9:30 AM, make 24 hr supply, and deliver cart at 4 PM.  Lots of waste because a lot or IV orders change after we start compounding.  Not being a 24 hr pharmacy means we have to make 24 hr at a time.  Unfortunately we are using fewer premixes now than a couple of years ago because of budget squeeze on inventory.  No matter about labor cost for mixing.  Admin looks at them separately I guess.  They are more worried about inventory expense than payroll.

 

When we got the isolators a few years ago the hosp. thought they were going to save money on not building a cleanroom.  They were wrong.  We now have pos. and neg. pressure rooms with anteroom between.  The only way you can work as fast in an isolator as in LAFW is to use 2 techs instead of one, but we don't have the luxury.  It can get very busy and we can get behind on IVs fast.  We try to limit the patient orders in the isolator to only one patient at a time to avoid mixups but that is extremely slow.  The techs try to pick out orders that are for same thing and do them all together so don't have to worry about mixing up labels.

 

Wish we could have 2 compounding sessions during the day but we are already compounding for most of the day.

 

By the way, when you do glove fingertip sampling after compounding in the isolator, how does the tech handle the plate without contaminating the gloves they are hoping are still sterile?  If I put a plate in the pass through I have to handle it and could of course contaminate the outside if not careful.  Then the tech could contaminate their gloves when handling it.  Just wondering.

 

Also, not supposed to put paper labels in insolator but in haz compounding the bag is ziplocked in the isolator before removing from isolator.  How do you put the label directly on the chemo bag?  We decided to just label in the hood.  Pharmacist looks at it before tech applies it.  Label has no RPh initials on it as a result.

 

Just some things I've been wondering about.

 

Thanks for input.

 

Robert Martin, PharmD

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Posts: 44
Registered: ‎06-30-2011
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Re: Efficient Workflow in a CAI/CACI

 

As far as the fingertip testing goes, I test the technicians immediately before they use the isolators in the anteroom after scrubbing their hands and using the Purell, then they remove the soiled gloves and place a pair of new sterile gloves in the isolator.  The premise of the fingertip test is to determine if they can place a pair of gloves on without contaminating them.  Since only one pair of hands are allowed in the isolator, I make them do the test in the anteroom after scrubbing their hands and, then, using the Purell. After the test I watched them place their sterile gloves on in the isolator to determine if they can do this within the confines of the isolator.  I record this on their competency form.  I do also have two laminar flow hoods that we use for the main hospital pharmacy to compound custom doses and perform our batching.  I train both our pharmacists and technicians in the proper use of the CAI, LFH  and CACI.

 

As far as the labeling for hazardous drugs is concern, our technicians do label the IV bag immediately before putting the bag within the isolator to compound.  We do have a separate form that contains the antineoplastic order that is generated when the physician writes the order.  The form contains an area for the oncology pharmacist's calculations and review of the protocol.  Within this form is an area for technician and pharmacist initials.  Hence, our technicians and pharmacists do not need to initial the actual bag but, rather, the form.  The form is kept permanently as part of the PMR. 

Carlos M Marin, RPh
Lead Pharmacist/IV Room/Oncology
Overlook Medical Center
99 Beauvoir Ave
Summit, NJ 07901
MailBox #277
O: (908) 522-2294
F: (908) 908-522-2583
carlos.marin@atlantichealth.org

It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature. ~John Brown
Frequent Advisor
Posts: 61
Registered: ‎05-18-2011
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Re: Efficient Workflow in a CAI/CACI

I have wondered about contaminating the glove tips myself. I do all the glove tip sampling for our dept. What I started doing was this. I wash my hands before i get the plates from the refrig. I bring them into our IV CAI room and place them on our cart. I use our automatic hand santizer dispenser we have placed in the rooms to resanitize my hands. I take a sterile wiper and place it on our cart and wipe down the exterior of the plate, currently I used 70% Sterile IPA. I take the sterile wiper with the plates on it and place it into our ante chamber, not touching the plates again with my hands, only touching the wiper. I place my hands in the CAI with the sterile gloves. I then use the gloves to open the door and bring the only the plates (not the wiper) into the direct compounding area of the CAI and perform the glove tip sampling. I try to do this toward the end of the dayshift and I change the gloves after I perform the test. In this way, I am trying to not contaminate the exterior of the plates. I hope this helps.

 

Patti

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Posts: 81
Registered: ‎04-05-2010
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Re: Efficient Workflow in a CAI/CACI

Patti,

 

Thanks.  That sounds like a good way to do it.  Only one question.  How do you make sure you don't contaminate the sterile isolator gloves when you open the inside pass-through door?  Do you spray and wipe the handle before putting the sterile gloves over the isolator gloves?

 

Robert

Frequent Advisor
Posts: 81
Registered: ‎04-05-2010
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Re: Efficient Workflow in a CAI/CACI

Carlos,

 

I may be wrong, but I was thinking that the first time validation with the 3 zero cfu requirement was done in the anteroom after gowning (as you said), but the annual (or semi-annual if you do high risk) revalidations were done in the hood/CAI when the individual was doing their annual media challenge.  Is this not so?

 

Thanks,

Robert

Frequent Advisor
Posts: 81
Registered: ‎04-05-2010
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Re: Efficient Workflow in a CAI/CACI

Carlos,


I may be wrong, but I was thinking that the first time validation with the 3 zero cfu requirement was done in the anteroom after gowning (as you said), but the annual (or semi-annual if you do high risk) revalidations were done in the hood/CAI when the individual was doing their annual media challenge.  Is this not so?


Thanks,

Robert

VIP
VIP
Posts: 44
Registered: ‎06-30-2011

Re: Efficient Workflow in a CAI/CACI

Robert,

 

You are correct in that the annual challenge is done in the hood along with the PATT2 test.  However, since our CAI is not accessible by more than one person, I carry out all our annual challenge in our laminar air flow hoods.  This way the person doing the test will not touch the agar plate and possibly contaminate the results.  Now, the initial fingertip and PATT2 validations occur in buffer room in the laminar air flow.  The isolator is used only after the new personnel can demonstrate knowledge and correct procedures in the laminar air flow hoods. I do, however, observe the IV room personnel putting on sterile gloves within the CAI or CACI to determine their ability to put on gloves without contaminating them.  Routinely, I observe all IV room personnel (in both isolators and LFH) to determine any bad habits that may be emerging.  We do not compound high risk medication at our hospital and routinely outsource them.  I do ask that the outsourcing company provide me with quarterly QA reports.  I will make visits to the company for observation of their operation and to see for myself if they are doing what they tell me.

 

Carlos

Carlos M Marin, RPh
Lead Pharmacist/IV Room/Oncology
Overlook Medical Center
99 Beauvoir Ave
Summit, NJ 07901
MailBox #277
O: (908) 522-2294
F: (908) 908-522-2583
carlos.marin@atlantichealth.org

It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature. ~John Brown
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Frequent Advisor
Posts: 81
Registered: ‎04-05-2010
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Re: Efficient Workflow in a CAI/CACI

OK, I missed that about the laminar flow hood.  Unfortunately we don't have one any longer.  When USP 797 was relatively new, the hospital thought they would save a lot of money getting rid of the laminar flow hood and buying a CAI and CACI SO THEY WOULDN'T HAVE TO BUILD A CLEANROOM.  Ha.  Little did they know!

 

Robert