9 tips for adding automation to IV compounding sites

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IV-WMS and robotics:

9 Steps for Implementing Tech Solutions in the IV Room

By Gina Shaw

Phoenix—At least nine different IV workflow management systems (IVWMS) and seven different IV robotics systems are available for hospital pharmacies’ IV compounding needs as of this summer. Choosing the right one depends on several key factors that technology leaders should heed when evaluating a purchase, two compounding experts noted at the 2022 ASHP Summer Meetings and Exhibition.

The technology ranges from basic, affordable but still very functional systems to multimillion-dollar, fully automated robotic IV compounding systems, noted Michael Freudiger, PharmD, the compounding and regulatory compliance supervisor at Valley Children’s Healthcare, in Madera, Calif.

“What you select will depend on your institution’s needs, but it is common sense that any hospital that does IV compounding should have at least one of these solutions,” Dr. Freudiger told Pharmacy Practice News. “IV workflow management systems may not be mandated as of yet, but they should be the industry standard.”

Dr. Freudiger and Patricia Kienle, RPh, MPA, BCSCP, the director of Accreditation and Medication Safety for Cardinal Health, offered nine recommendations for choosing the right IV-WMS and/or robotics system:

Do a gap analysis. “Bring together a team to assess where errors are most likely to occur in your IV compounding setup based on your work practices,” Ms. Kienle said. “That team should ideally include not only leadership from the pharmacy, but also the risk manager for your facility, who likely knows about safety gaps that have occurred that may be confidential to the rest of the organization. They see the bigger picture.”

Ms. Kienle also advised involving nursing expertise, including an infection control nurse and, if you have a significant oncology practice, an oncology nurse. “These nurses can see gaps from an end-user perspective that may be missed in the pharmacy.”

Know your options (see Table 1) and use a scorecard to rate

them. “After you’ve assessed your system’s needs, review the available technologies and see where those systems would line up with your requirements,” Dr. Freudiger said. For IV-WMS, he suggested starting with several fundamental desired features, including barcode scanning and automation (a must); gravimetric verification, which the Institute for Safe Medication Practices (ISMP) states is optimal; electronic documentation for remote verification; dose tracking; and integration with other systems. “That last item can be particularly variable and institution-specific,” he said.

Table 1. What’s Currently in Use

IV workflow management systems

• BD Pyxis IV Prep (Becton Dickinson)—formerly BD Cato • IVX Workflow (Omnicell) • i.v.SOFT Assist (Omnicell)—discontinueda • DoseEdge (Baxter) • Dispense Prep (Epic) • PharmacyKeeper (Grifols) • Assure-Trak (ConsortiEX) • DrugCam (Eurekam) • Diana Compounding Workflow System (ICU Medical)

IV robotic systems

• APOTECAchemo (Loccioni)

• RIVA (ARxIUM; Intelligent Hospital Systems)

• INTELLIFILL I.V. (Baxa Healthcare)—discontinued

• Equashield Pro (Equashield LLC) (CSTD robot) • KIRO Oncology (Grifols USA)

• i.v.STATION (Omnicell)

• i.v.STATION ONCO (Omnicell)

• IVX Station (Omnicell)—new in 2022

Table 2. The Pros and Cons of IV Robotic Systems

Benefits

• Increase patient safety (medication safety) • Standardize products to meet the hospital’s needs • Create a more reliable supply of compounded preparations (less need for premade products) • Batch produce high-use (high-volume) preparations • Control and reduce costs; reduce waste • Reduce the workloads from manual (human) compounding • Record all steps of production process • Increased efficiency in workflow • Bags from 25–1,000 mL can be produced quickly • Syringes from 0.3–60 mL can be produced quickly • Gravimetric checks of stock items with barcodes • Step-by-step checks during compounding • Step-by-step photo log of each compounding step • Internal automated labeling of the final product • Some robots can compound hazardous drugs

Disadvantages

• Time to prepare products can be slower in some situations

• More employee training involved • Higher costs (should be offset by savings) • Need for frequent updates to drug libraries

Source: Michael Freudiger, PharmD.

“Everyone will have a different combination of electronic health records and other technologies at their hospital, so check with the vendor to see if it integrates with what you have.” You can then add other items to your scorecard that might be helpful to have, such as integration with other hardware, realtime video recognition of drug vials and syringe volumes, or incorporation of closed system drug-transfer devices for chemotherapy, he noted.

Understand the capital require-

ments. The cost of these systems can range from the low five figures for a basic IV-WMS to well over $1 million for IV robots. “You need to convince your hospital administration of the need to make these technologies a budget priority, and that best practices are evolving fairly quickly because of the growing number of systems that are out there,” Ms. Kienle said. If you’re putting an IV robot system in place, continuing costs also are significant. “You will also need an annual budget for maintenance and replacement parts, calibration of the equipment, cleaning of machinery, personnel, training of new staff, and training of the robot or robots for new drug vials,” Dr. Freudiger said.

For robotic systems, consider

return on investment. “The significant costs associated with an IV robot mean that you have to make a lot of product for it to be a good return on your investment,” Dr. Freudiger noted. “In a large hospital or healthcare system, a robot makes a lot of sense because it will allow you to produce enough preparations to reduce your reliance on outsourced products. If you only make a handful of IV preparations per day, however, you are probably better off with a good IV workflow management system alone. With robots, you also need to think about space—many of these systems are extremely large—and how you will physically get it into your facility.”

Assess staffing. For most IVWMS, you probably don’t need any new staffing, but training of existing staff should be a priority. “With IV workflow systems, you buy it, put it in the hood, get training on the program and follow the steps. It alters your methods but not that much,” Dr. Freudiger said. “The robot, on the other hand, requires a whole new dedicated staff to operate and maintain it.”

Prepare an implementation plan.

“Review your pharmacy sterile products workloads and identify your needs based on your patient population,” he said. “You will want to coordinate with your IT department, particularly networking, and consider extra staffing during the implementation period. Develop a very detailed calendar with all the steps involved, and consult with the vendor on your time line for implementation.”

Go live gradually. “Formulate a plan for starting with a few highvolume use products and do a gradual ‘go-live’ with the systems,” Dr. Freudiger said.

Expect system downtime and

have a backup plan. “We know that IV workflow and IV robotics systems will go down at times, so don’t make the mistake of replacing your current system with this technology and forgetting how to do things the old-fashioned way,” Dr. Freudiger noted. “Put a backup plan in place for unexpected downtime, and practice your backup plan every three to six months. If the system goes down, could you still function?”

Understand and prepare to overcome potential barriers to

success. For IV robot systems, Dr. Freudiger said, obstacles can include inadequate space to install the robot, insufficient staff members to operate the machine(s), suboptimal employee education and support, inability to integrate the robot into other hospital systems, acquiring a robot that can only produce syringes and not bags, and the need to always add new National Drug Code (NDC) numbers and barcodes into the system. For IV-WMS, these barriers can include drug shortages requiring frequent addition of new NDC numbers and barcodes to the system, failure to interface with existing computerized prescriber order entry systems, and unexpected costs for things like maintenance, cleaning, upgrades and staff training, as well as construction costs for installation of larger systems.

Use ISMP Guidelines

Dr. Freudiger also recommended that institutions employing these technologies or considering their implementation make use of the ISMP’s May 2022 publication, “Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology,” available online (bit.ly/3AdM2U9).

Dr. Freudiger reported no relevant financial disclosures. Ms. Kienle is an employee of Cardinal Health and a member of the USP Compounding Expert Committee. The comments in this article are her own.