Going cartless

I spent some time recently speaking with the director of pharmacy (DOP) from a large acute care facility about operations and various dispensing models. In this particular instance, the hospital utilizes a cartfill model, decentralized pharmacists in satellites to handle first doses, batched IV’s and automated dispensing cabinets for pain meds and other “PRN” medications.

At one point the conversation drifted toward a discussion of using a cartless dispensing model. The DOP wasn’t a fan. The reason cited was a fear that utilizing automated dispensing cabinets in a cartless model would create a workflow logjam in the pharmacy as the entire day would be dedicated to “massive ADC [automated dispensing cabinet] fills”. I understand the thought process, but have found through experience that this simply isn’t true. In a well-constructed workflow a cartless model is quite efficient.

I’ve worked in several acute care pharmacies, including some that utilized a cartfill model and some that utilized a cartless model. Based on my experiences with both, I’ve found that the cartfill model is by far the most complicated; the most labor intensive; and most wasteful of all dispensing modalities. The typical cartfill is designed to cover a patient’s medication needs for a predetermined period of time; 12 to 24 hours in most cases. The problem is that most patients in an acute care environment are moving targets when it comes to their medication needs. This results in the medications in a cartfill model being out of date five minutes into the fill. Top it off with the fact that most of the day is spent filling the carts, updating the carts and checking the carts for accuracy, and it becomes a real hassle.

My initial reaction was that the DOP’s thought process was “old school” thinking, but I’ve seen recent discussion on pharmacy listervs regarding a movement away from ADC dispensing and back toward a cartfill model. The most common reason cited for the trend is patient safety. I’m befuddled by that rationale, as I don’t think centralized dispensing from carts is any safer than dispensing from ADCs on the floor. In fact, I would argue the opposite, but that’s for another time.

So if it’s not old school thinking does that mean that the centralized cartfill model is cutting edge? Nah, there’s certainly nothing cutting edge about a centralized dispensing model. My personal belief is that the problem is twofold. First, the unknown creates fear among pharmacy departments. Change is hard, especially when you lack resources to go fishing for a solution. So you tend to stick with what you know. And the centralized unit-dose cart fill has been around for a long time. Second, pharmacy develops preconceived notions often based on the failure of others. I doubt the DOP I was speaking to had ever seen a cartless system in action; at least not a good one. Some of the things that were said demonstrated a clear lack of understanding for the cartless model.

With all the talk about recreating the pharmacy practice model, i.e. PPMI, it feels odd that someone would promote a system designed several decades ago. With advancing technologies and improved workflow, the idea of moving the bulk of medication dispensing back into the pharmacy seems backward.

Robotics, automated storage, bulk packaging, IV room technologies, mobile devices, tech-check-tech, automated dispensing cabinets, computerized provider order entry, automated order verification, etc. are all designed to move the pharmacist out of the pharmacy toward the patient bedside. Centralized order processing, i.e. pharmacist order entry, centralized cartfill, etc. are designed to pull pharmacists back into the physical pharmacy away from the patient bedside.

I’ve had the good fortune of being born with a short attention span, which has resulted in me working in a total of six acute care hospitals of all shapes and sizes over the past 13 years. I’ve worked in facilities ranging from 50 beds to over six hundred; cartfill and cartless models; decentralized dispensing and centralized dispensing; single, large pharmacies and satellite pharmacies; technician order entry and pharmacist order entry. And the pharmacies with the best clinical pharmacy services were those that utilized a decentralized pharmacy model with satellites and extensive use of automated dispensing cabinets. The pharmacies with the worst clinical services were those that had pharmacists centralized with a cartfill model. Go figure.

Some advantages of a cartless model:

1. Availability of medications at the point-of-care – Turnaround time is important in a hospital and is often used as a measure of success in a pharmacy department.
2. Fewer missing medications – It’s hard to have a missing medication when all you have to do is go to an ADC to get it out.
3. Patient safety – This is a wash. Some pharmacists argue that dispensing from ADCs is unsafe secondary to easy access to drugs. This is simply not true. When utilized properly, with appropriate safeguards in place, dispensing from ADCs is perfectly safe. On the flipside, having medications available in a med cart gives providers open access. How many pharmacists out there have heard the phrase “I borrowed one from [insert patient name here]”? Scary.
4. Better control of medication access – Gaining access to ADCs typically requires some form of user identification/verification.
5. Analytics – It’s much easier to run reports and collect data when access is controlled via ADCs.
6. Increased pharmacist freedom – I’m a firm believer that a well-designed cartless system requires less pharmacist time than a system designed around 24 hour cartfills.

Some disadvantages of a cartless model:

1. Larger ADC fills – There’s no way to get around this. However, the increased labor resources needed for a cartless model are easily recovered from removal of the cartfill process.
2. Frequent updates to ADCs – If you’re going to dispense more than 90% of your medications from ADCs then you’re going to have to keep up with your patient’s needs. This means addressing changes to ADC contents in real time; simple adjustment to workflow.
3. Expense – The more you dispense from ADCs the more ADCs you’re facility will need. It’s simple logic, but something that escapes many people. Yes, it is expensive, but the ROI is worth it when done properly.

Cartless model myths:

1. Cartless means no cart fill – Sorry to break it to you, but cartless doesn’t mean you can completely eliminate the “cartfill” process. You’ll always have those items that just can’t go in an ADC or require a different method of distribution for one reason or another. With that said, it’s completely within reason to get >90% of your patient’s medication needs from ADCs.
2. The technicians will spend their entire day filling ADCs – Not true. The workflow is different, but time spent on the ADCs will be less than that spent on cartfill. Trust me.
3. Pharmacists will spend too much time checking ADC fills – Really? How much time do you think pharmacists spend checking and re-checking cart fills? It’s a lot. Don’t try this argument on me because it simple doesn’t hold water. I’ve done both, and can’t believe the difference.
4. The nurses will hate it – I’ve worked with many nurses, and a vast majority love the cartless model. The reason is simple: they love the idea of accessing medications at the point-of-care at their convenience. One of the biggest riffs between nursing and pharmacy is turn-around time and slow delivery of medications. Both are improved with a cartless model.