Emergency Dispensing Protocols: Pharmacy Departmental Preparedness
One of the more common types of downtime is a single sided downtime with is when orders entered can technically be verified by pharmacy, but some error or update limits the ability for the providers to enter the orders either locally or throughout a system. Single sided MD/RN downtime can technically be managed off site if the location’s IT infrastructure is the issue, with other hospitals or clinics able to enter in the orders for the physicians. This solution is burdensome at anything larger than small scale and introduces its own potential for medical errors. Often case the common and best solution even in a single sided downtime is a return to paper orders and charts. Transmission of the orders to the pharmacy either via fax or if available pneumatic tube. Verbal orders via telephone or Epic/Teams may be convenient in this instance but lacks the permanent and recordable record that paper orders provide.
Two-sided downtime is when the entire eMAR in operable for both order entry and order verification. Specifically, when only Pharmacy has downtime, this is treated the same as two-sided downtime as the inability to see and verify the orders results in the same outcome. This necessitates a full paper rollout for orders and charting as well as a pivot towards creating labeling for medications outside of the eMAR generated labeling. Orders received and dispensed during any downtime should be entered into the eMAR when the issues have resolved so as to provide an account of record for future needs.
There is a small point to touch on for planned downtime and catastrophic downtime as well. Where planned downtime is announced ahead of time and can be planned for (see printing of MAR copies and prepping of labels) expansion of the downtime past the designated times may interrupt bath printing procedures for both scheduled IV therapies as well as potential patient med fill for the next day if done via hand pick or machine. This extended downtime is usually not well communicated until reaching the time of or past the regularly scheduled downtime expiration and as it is usually due to extraneous circumstances the resolution is unknown. This necessitates a robust and aggressive pivot towards ensuring that workflow is protected. Ample preparation for downtime procedures with a near seamless transition will decrease operational disruption and maintain quality of patient care. Scrambling after the fact does noting more than add additional stress.
Luckily most hospitals have a robust backup power management system as well as more nuanced disaster protocols when those are ineffective. Beyond a brief power outage/fluctuation when the hospital switches to backup power this first stage is mostly an inconvenience. With a failure or outlast of the backups is where departmental disaster management becomes more crucial. In planned downtime the ability to print the entire hospitals inpatient profile and medications. When the downtime is sudden or catastrophic that may not be immediately possible, requiring a relocation of that information to a stable area in order to print or generate that information. With that comes the implication that labels will no longer generate and print. With the preferred power-based solution of computer and custom typed label format created on Microsoft Word. As long as any generator power supply is available or battery banks, this may still be feasible as the power draw of a laptop and zebra printer for example is not very high. In these situations, fax machines may not be operational as although phone lines are easily powered and require much lower voltage for operation, that current implementation of fax machines in health systems may be operating as an auto-printing email service rather than as traditional fax. Order transmission with faxing potentially being down and the implication that other methods such as pneumatic tubing are also inoperable will require the expansion of the pharmacy footprint to a runner or satellite-based format. Proper utilization of runners in this case would be of pharmacy technicians to transit both medications and orders back and forth to the pharmacy dispensing area. With scanning tools impacted either duplicate of orders generated should be done at time of writing or utilization of carbon paper orders so that the original may live in the patient’s chart at bedside.
For specific pharmacy preparation, they should be robust, reproducible, and retrievable. The scrambling to create a label template when the world is burning around you is not optimal for anyone. A workshopped editable template that works for both label printers and regular printers is the optimal first step. Please not that this must conform to federal and state regulations of prescription labeling so please ensure all patient, prescriber, and pharmacy information is properly prepared. More robustly is creating multiple templates for the format of the medication being dispensed, one for solid oral doses doesn’t usually operate well for IV medications or TPN infusions. When finalized the essential information should be stored in a centrally accessible area on the server and physically as well with preprinted blanks on the shelf helping smooth the transition to extended downtime. File information stored on a physical USB device is also extremely helpful as it allows multiple computers access to the information when the central server is down and allows the ability to print the documents at an outside area that is unaffected.
Most hospital systems have an ingrained and smooth cycle of replacing printed information of policies and procedures which are often on hand in a local office. This is less true for some more specific guidelines and protocols. With such a hard pivot away from paper orders for high-risk infusions such as oncology, they are often just kept electronically. It may be beneficial on a disaster preparedness level to ensure that copies of those order sheets are kept physically printed and updated yearly or stored locally such as a USB. Compounding guides or protocols would also benefit from having a physically printed version, so downtime staff are easily able to adjust to the changes. This of course is partially ignoring the implication that with power loss the air flow and sterile compounding areas may be compromised for employees as ventilation may not conform to usp800 standards. Ad hoc compounding may potentially occur under usp797 for certain medications depending on the ability to sterilize the area but adjusted immediate use dating would be required.
In previous years the preferred emergency backup were typewriters. This also included electric typewriters up until a certain time but as they also rely on a steady electric supply, they have inherently the same weakness as a computer/printer combination. With a mechanical typewriter the requirements are basic enough to be reproducible as long as you have ink ribbons and enough paper. The rapid phase in of advanced technology for pharmacy dispensing also usually coincided with those departments getting rid of their typewriters in an attempt to shore up local space. With the current hospital dispensing framework and overall hospital operation being so intrinsically tied to electronics, any sustained power loss becomes such an insurmountable burden for care that the benefits of the pharmacy being prepared would pale in the chaos of the rest of the hospital not being able to function at all with a >24h power loss. The benefit of holding a few small modern footprint typewriters with supplies in the emergency staging area of the hospital can do noting but help in time of disaster, you’ll just have to hope you have experienced team members on hand to help teach younger staff how to operate it!
