by donna rogers, editor-in-chief keeping tabs onmeds

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BY DONNA ROGERS, EDITOR-IN-CHIEF

KEEPING TABS ONMEDS

Eif dispens ing medications was ever easy, pharmacy delivery sys

tems just got that much more difficult due to COVID-19. Preparing medications for a transient population is time consuming and labor intensive. Medication inventory management and delivery to the patient must be accurate to prevent missing medications, unlabeled doses, undel ivered meds and dos ing errors. Of course, carrying too large an inventory can go to waste when an offender is moved or released, resulting in financial losses for the facility.

18 CORRECTIONS FORUM • MAY/JUNE 2020

Omnicell XT Automated Dispensing Cabinets (ADCs) provide several

safety benefits for both the health care worker and the inmate.

"The act of writing the prescription may be the least complicated process in a correctional facility's medication use system," points out Deleca ReynoldsBarnes, PharmD, vice president of Pharmacy, with Wellpath (formerly known as Correct Care Solutions), a healthcare company focusing on corrections based in Nashville, Tennessee.

Filling regular prescr iptions quickly and effic iently when health care workers may be short staffed and population are falling sick is all the more important in today1s environment.

Dispens ing medications

methodically in corrections facilities requires a comprehensive and multi-faceted process, says Reynolds-Barnes. It all begins at intake, she adds. Before putting pen to paper ( or actually typing the prescription into the electronic health record), the medication h istory is imperative to ensure the appropriate medications are prescribed.

Following a review of the intake medication records, medication reconciliation should be completed, which is the comprehensive evaluation of patient1s medication regimen, due to a transition in care, to avoid med-

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ication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns, she asserts.

The second key to ensuring the availability of medications is having an inventory system that ensures par level management of non-patient specific and patient specific medications. Medications kept in the medication room and on medication carts should be included, as well as tools to easily track the locations medications within the facility.

Reynolds-Barnes furthers that barcode technology, while often used in the medication administration process, is also an important tool for the inventory process. She says multiple medication dispensing systems are available to correctional facilities based on individual state board of pharmacy and federal regulations. "There is no single perfect dispensing system and often a combination of systems offer the best option to ensure availability of all medications at the scheduled administration system."

Blister cards/bubble packaging, the most common correctional facility medication packaging system, use little space and offer an efficient medication cart storage

state specific licensure requirements addressing the need for an onsite pharmacy and/or pharmacist would need to fully vetted."

Another implementation option, notes Reynolds-Barnes, is receiving medications from your pharmacy in compliance packaging. This would require receiving significantly less than a 30 days' supply (usually 1-7 days), and having appropriate medication storage system. Inhouse processes to manage this system are essential and the facility often loses the opportunity for returns and credits. Frequent patient medication changes are often cited as the reason these systems are not frequently used.

The third option is the use of automated point of care dispensing machines in conjunction with a licensed pharmacy (i.e., Pyxis, Omnicell, MedDispense, etc ... ). Again, the ability to use these systems require an in-depth review of state board of pharmacy regulations. If allowed at a facility, you often gain the benefit of a perpetual inventory system with barcode technology. These systems can alert the nursing staff and pharmacy prior to the administration of the needed medications.

The following are examples of a variety of these systems-both

The "Eight Rights" of Medication Administration The nurse will give the right dose of the right medication to the

right patient via the right route at the right time for the right reason, perform the right documentation, and get the right response from the medication.

option. The use of compliance packaging is another packing system option. While it has been shown to decrease the time the nursing staff spends in the medication administration process, it is imperative that nursing has a system to review for medication changes prior to the administration cycle. Wellpath's pharmacist cautions that "The implementation of these system would require installing these systems on site and

-WEXFORD HEALTH

manual and automated-that prisons and jails employ to streamline the process and maintain control of their inventories.

Celebrating its 50th year, MediDose/EPS has been working with pharmacists and health care professionals to design and support cost-effective products solving the specific needs of their practices. Its Medi-Dose System is used by correctional facilities of all sizes to package solid oral, unit dose med-

SllnSlt&

Swisslog Healthcare's lnSite In

Facility Medication Packaging and

Dispensing System stores up to 240

different medication types.

ications. The company's EPS division provides liquid packaging, tamper evident bottles, tapes and other ancillary items.

Working with pharmacists and technicians, the company reports the Medi-Dose system has been designed to be an easy and costeffective way to unit dose and bar code medical inventory. Because of its cold seal technology, it doesn't require special inservice training and staff can easily package blister packs with only inhouse supervision. "It 's all manual and easy to do and learn," says Bob Braverman, president. "The technician or pharmacist takes the blister, places it into our template, dispenses the medication into the blisters, peels the label, places it on the blisters and, just like that, they've just packaged 25 doses of medication. With the Medi-Dose system, all of the meds can be identified with the medication name, generic name, right down to a bar code and expiration date ... whatever is pertinent," he says.

The optional software is inexpensive, he says-about $500 to purchase new-and is easy to learn. Tech support is free and continues for the life of product. Custom written for pharmacies, it offers flexibility, and a variety of bar coding options that can be customized by the customer, with

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any font or graphic, for example, and that format can be automatically saved for the next time the medication is selected. Designed with security in mind, only supervisors with permissions can change the fields. The software provides accountability-it records all labels and allows reports to be generated on types of medications packed, on lot numbers in case of a recall, on meds packed by a particular employee and more. "A variety of checks can be turned on or offthey are all optional, 11 notes Braverman.

The system works for both large and small facilities, he explains. "We've been told by countless hospitals, pharmacists, nurses, that we offer a time saver and have reduced medical error.

Perhaps it's a testament to the company that "SO years have come and gone and we're still here, 11 he says. "We offer new blisters, new shapes, different plastics, enhanced options, but the general nuts and bolts of system are the same, and we add new customers every day." In fact, he adds, "we've become a go-to for people, particularly in these uncertain times."

Comprehensive

Pharmacy Another option agencies

deploy is system of overarching pharmacy care. Diamond Pharmacy Services has been providing these types of services to state, county and juvenile correctional facilities since 1983. Currently, it serves nearly 700,000 correctional patients in 46 states.

Diamond's comprehensive pharmacy services program entails prescription dispensing, pharmacy management and a strong clinical program to ensure patients receive the proper drug therapy for the best clinical outcome at the most competitive price. "This means more than just medications," says Mark Zilner,


COO. Outside of prescriptions and

medical supplies, Diamond offers overnight delivery, 24/7 pharmacist consultation, formulary management, robust reporting services, credit on returned medications and free electronic ordering and record management through Sapphire eMAR (electronic Medication Administration Record) as well as offer Sapphire EHR (electronic health record), both developed solely for the correctional market. (Ed note:

SapphireHealth is the maker of Sapphire eMAR/EHR, the electronic system provided by Diamond Pharmacy Services.)

Diamond offers several ways to order. Traditional phone or fax methods are available, but many facilities are looking for an electronic solution, which is where Sapphire comes in, the company explains. Orders are transmitted to Diamond via Sapphire, where it is processed by a technician and then reviewed by a clinical pharmacist. Once orders are packed and processed, they are once again reviewed by a pharmacist to further ensure accuracy, they note. This system, with numerous staff checks as well as a barcode driven component, helps to ensure the right inmate at the right facility receives the right medication. Facilities also use Sapphire to check in their order and to return medications.

"Quite simply, the benefits of a

system like this," says Zilner, "are accuracy and overall medication management. Accurate orders arriving to our facilities on time lead to better patient outcomes, save staff time, and keep a correctional facility's health care program running at the best possible level."

Sapphire screens for allergies, drug interactions, proper dosing,

· refills ordered too soon In addition to a stringent quality controlsystem for the ordering process,Diamond offers a prescriptionreconciliation program at thefacility level. This allows a facilityto scan all prescription orders toverify that what was ordered wasindeed received.

Zilner notes: A good eMAR system should provide an additional layer of quality control and accountability. The Sapphire eMAR, which is fully HIPAA compliant, enables for an accountable paperless med pass, which is barcode enabled permitting staff to verify that the right inmate is receiving the right medication at the right time.

Point of Care

Automation Omnicell, a Mountainview,

Calif., company likewise provides comprehensive pharmacy solutions including central pharmacy dispensing, intelligence and point of care automation. In the latter category, Omnicell XT

With the Medi-Dose cold seal system, the technician or pharmacist can quickly

package 25 doses of medication.


Automated Dispensing Cabinets (ADCs) provide "a smarter, safer process for getting the right medication to the right patient. They offer improved nurse-pharmacy workflows, medication inventory management capabilities, as well as enhanced medication safety and security, according to Len Hom, director of Product Marketing, Point of Use, Omnicell.

Omnicell1s XT ADCs provide several safety benefits for both the health care worker and the inmate. All medication orders written by a physician are reviewed and profiled by a pharmacist and are interfaced (via electronic health records) with the dispensing cabinet at the facility, he furthers. This allows real-time dispensing at the prison.

The XT also provides reports, ensuring accountability for all transactions including documentation on anyone who entered the high-security, doublelocked ADC.

"All controlled substances require a second witness to allow dispensing and a 'blind count,' meaning that the authorized person obtaining the medication has to count back and enter a quantity into the system," Hom details. "If the count varies from the amount that is supposed to be in the bin, a report is generated and must be addressed before end of shift."

As another safety benefit, when restocking, Omnicell's Safety Stock barcode verification ensures

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proper placement of medications. This includes the use of "guiding lights" to direct users to specific locked bins for restocking. External return bins allow medications to be returned safely to the pharmacy. The bins in the XT ADC are not removable, thus preventing infection control issues to and from the facility to the pharmacy, important at any time, but even more so today.

Automation Solutions Swisslog Healthcare combines advanced transport

and pharmacy automation solutions with integrated, accessible software to enhance performance and workflow efficiency, improve accuracy and enable better patient care. Parent company, Swisslog, a global company with Swiss roots, is one of the world's leading logistics automation companies.

Swisslog Healthcare 1 s InSite® In-Facility Medication Packaging and Dispensing System is utilized in numerous corrections settings, including many prisons and jails, packaging over 32 million doses annually to over 25,000 inmate patients. It stores up to 240 different medication types in a single medication dispensing unit, providing automated, on-demand compliance packaging for oral solid medications prior to administration. The pharmacy delivers bulk canisters of medications to be stored within the system.

Patient medication orders are transmitted to the pharmacist for clinical review. After approval, the orders are electronically sent to the InSite system and medications are immediately available at the corrections facility. Nursing or pharmacy staff runs the system for the medication call and it dispenses only the medications needed for the patients of that call. The medications can be dispensed by various sorting options, including inmate location. The orders are dispensed from the system in unit or multi-dose, patient-specific packaging. Medication is administered to the inmate at the inmate bedside or at the medication call line by the nurse. The InSite system keeps a record of each dispense.

"Our flexible automated solutions can meet a facility's changing requirements and enable them to meet the unique challenges of a transient patient population/' says Mike Carmody, vice president of Long-Term Care at Swisslog Healthcare. "By adopting the InSite in-facility medication packaging and dispensing, correctional facilities benefit from improved workflows and a more secure, efficient and accurate medication management process."

For example, the act of enabling automated packaging and dispensing within a correctional facility improves staff efficiency, reduces medication waste and saves time. The average InSite canister holds about 300 doses and can be filled and processed in roughly the same time it takes to create a single 30-day blister pack. "Traditional blister packaging of medications is an error-prone, labor-intensive med-

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ication management process, which is time-consuming. Automating packaging and dispensing dramatically reduces the time needed to prepare medication, by packaging up to 60 does per minute and providing a broad variety of sorting options," he says.

Wasted medications cost correctional facilities hundreds of thousands of dollars every year, according to Swisslog. Due to the transient nature of patients when people are transferred to other facilities, paroled or released, many medications go unused. (/Our automated solutions enable you to manage pharmacy inventory more effectively by packaging and dispensing medications on demand. The automated system provides complete visibility by tracking inmates' current location based on the latest dataeven if they are off-site or at court," Carmody points out.

(/The InSite System transforms the process of medication dis-

pensing in corrections facilities from a tedious, error prone set of tasks to an efficient, automated workflow. This ensures adherence to strict regulatory requirements as well as the legal rights of inmates," says Carmody. (/Ondemand medication access helps correctional facilities improve inmate care and nurse satisfaction through efficiency gains, while offsetting the financial burden of rising drug costs and reducing medication waste."

Effective eMARs Dispensing medications

methodically remains a constant challenge, concurs Martha Ingram, RN, CCHP, CPHQ, director of Quality Management & Performance Improvement, Wexford Health. (/The sheer volume of medications to be received, checked, and administered to inmate patients is the number one challenge," she says.

She adds it is of utmost impor-

tance that correctional facilities and nursing staff have an organized, effective method in place for safely administering high volumes of medications to inmates on a daily basis.

One of the issues of medication dispensing is that it takes up the time of custody staff, she points out. While medication distribution and administration is typically the responsibility of nursing staff, custody officers are often required to accompany them. Facilities are looking for the most efficient method of medication administration to limit the amount of time that custody personnel are tied up with each medication distribution. Of course it is also important that the medication is accurately given to each person and appropriately documented, she continues.

To meet this challenge, for the majority of its clients, says Ingram,

MEDS: Continues on page 41

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Pulse Continued from page 8

immediate release of inmates who are detained solely on the basis of their inability to satisfy a financial condition of pretrial release, or solely on the basis of a technical violation of probation or parole; and inspection of the jail by a qualified public health expert to document the actions needed to prevent the spread of COVID-19 in the jail, including to enable social distancing among those living and working in the jail.

WEBINAR ON REOPENING

READINESS

The American Jail Association partnered with jail administrators across the country to hold a webinar on May 20 that tackled reopening readiness. During the hourlong webinar, corrections leaders shared their plans for reopening their facilities during the pandemic, and discussed the steps their agencies are taking to make staff care a priority. The recording is available through the AJA home page.

'WE NEED TO STEM THE

SPREAD OF COVID-19

AMONG INMATES' Hillsborough's former jail direc

tor wrote an opinion piece in a Florida newspaper on how to cool down the hot spots in correctional facilities. In the May 11 edition of the Tampa Bay Times Col. David Parrish (Ret.) wrote: "During this

MEDS: Continued from page 26

Wexford Health uses electronic Medication Administration Reports (eMARs) to help streamline the organization and administration of the medication pass. "EMARs are a safer, more reliable, and accurate form of documenting medication administration," Ingram notes. For clients who do not have an eMAR, she says they use standard paper MARs, doing things manually, which is also a viable option. "The bottom line is to ensure the continuity of an inmate's medication upon his/her arrival at a facility ac-


global pandemic, we must do all we can to slow the spread of COVID-19 and flatten the curve. Unfortunately, Florida's prisons and jails are poised to incubate and spread the virus. Fifty-four prisons already have positive cases, including 180 just discovered at Liberty Correctional Institution. Gov. Ron DeSantis can assist in slowing the spread by taking executive action to (1) remove prisoners who pose little threat to public safety, (2) encourage local authorities to do the same thing for people held pre-trial in county jails and (3) direct that all inmates and staff in correctional facilities be tested."

In order to prevent the cases in our prisons and jails from spreading like wildfire behind bars and out into the surrounding community, we need to know who has the virus. When testing was mandated at the Marion Correctional Institution in Ohio, approximately 2,000 out of 2,400 inmates, and almost 200 staff, tested positive, he pointed out. Tennessee Gov. Bill Lee just announced that every corrections officer and incarcerated person in his state will be tested. Florida should follow suit. The governor needs to ensure that correctional administrators can conduct universal testing. The staff, incarcerated people, and general public deserve no less, he opined.

Florida should also reduce the prison population, as other states have done. North Dakota granted early parole to 50 people and Ohio's governor released 100 individuals

cording to ACA and NCCHC standards; to provide uninterrupted medication throughout the inmate's incarceration; and to confirm proper documentation of medication administration in the inmate's medical record."

An eMAR provides high security and protection for patient information while ensuring compliance to HIPAA regulations. Nurses can set up multiple med-passes by unit, wing, room, and bed with eMARs through interfaces with many different offender management systems. With the use of currently

who pose little threat to society. Attorney General William Barr has directed the Bureau of Prisons to make significant releases. I applaud these leaders for acting quickly to diminish the risk of transmission.

Finally, across the state, counties can greatly reduce the chance of an epidemic in local jails by removing people who pose no real public safety risk. About two thirds of the peqple in a typical jail are being held pretrial, many because they cannot afford a few hundred dollars. Some local leaders have already reduced their jail populations by removing people held for low bail amounts. They are not releasing people held for serious offenses, just those who would already be out on bond if they had the cash. The governor should encourage each county to follow suit, he said.

AJA ESTABLISHES COVID-19

RELIEF FUND

The American Jail Association, in conjunction with its generous business partners, has established a Corrections Officer Relief Fund to assist those affected by the pandemic. To be considered for assistance, complete and submit an application form (americanjail.org), along with a letter from your jail administrator or sheriff confirming your eligibility. All applicants will be evaluated by the AJA Corrections Officer Relief Fund committee to determine eligibility and award amount. There is also a place on the site to donate to the fund. 0

available barcode technology, nurses can identify patients and their medication blister cards to ensure the "eight rights of medication administration." (See box page 20.)

During this unprecedented time, when Covid-19 is adversely impacting prisons and jails, all these tools can offer relief. They help to reduce the labor intensive process of passing out medications, get meds to those who need them quickly and lower the financial burdens of providing the necessary drugs to those in your custody. 0

CORRECTIONS FORUM • MAY/JUNE 2020 41

by donna rogers, editor-in-chief keeping tabs onmeds

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