Ms Kathy Lai-ki MAK, MR Ivan Chi-hung WONG, Ms Daisy Chiu-ling CHIA Pharmacy Department, Tseung Kwan O Hospital Integrated Inpatient and Outpatient Dispensing Section in Pharmacy Department Tseung Kwan O Hospital, Hong Kong Background Tseung Kwan O Hospital is a new hospital and commenced its operation in late December, 1999. It was built as a general acute hospital with 458 in-patient beds and 140 day beds. The scope of services includes 24 hours accident & emergency service, inpatients and outpatients services of various clinical specialties and allied health services. The core service of pharmacy department is to provide inpatient and outpatient dispensing services. Other supporting services include clinical pharmacy service, procurement of drugs and dressing items, drug distribution and manufacturing of pharmaceutical preparations. The department is operated with three pharmacists, fifteen dispensing staff and five supporting staff. Expectation from the patients on public health care services is growing in recent years. Waiting time for collection of medications for outpatients is one of indicators to the efficiency of pharmacy service. The goal of our department is to provide service with quality and efficiency. Therefore, it is our target to maintain the waiting time for outpatient prescriptions to not more than fifteen minutes. Another initiative to improve patient care is to capture a complete drug history for each inpatient. All prescribed medications are recorded into the computer including ward stock items. A complete drug profile is an essential tool for the screening of potential drug interactions and overdose. As a result, innovation and reengineering of the traditional pharmacy workflow is necessary to sustain the service standard. Therefore, the concept of integrated inpatient and outpatient dispensing section is introduced. Methods During commissioning phase of the pharmacy department, minimal fixtures such as workbenches or shelves were installed. It allowed more flexibility in the later stage of planning to design the layout of the dispensing area to meet the actual operational need. In the original design, the outpatient and inpatient dispensing sections were supposed to be separated at the two ends of the pharmacy in an open area. (Diagram 1) As a result, the two sections would be located far apart. To facilitate ease of dispensing, two separate working stores for medications and two teams of staff would be required to carry out the dispensing duties. Issuing Counters Concrete Pillar Diagram 1: Separated Inpatient &Outpatient Sections In order to achieve our targets, we integrated the two sections by moving the inpatient dispensing section right next to the outpatient dispensing section. The medication workstations procured for the dispensing areas are very versatile and flexible. We converted one side of outpatient workstation for medications to workstation for inpatient data entry. (Diagram 2) All non-parenteral medications are stocked in the outpatient section as they are commonly used for outpatients, whereas parenteral medications are stocked in the inpatient section. Express Dispensing System (EDS) is employed in the outpatient section. The concept is to locate items of different strengths, similar drug names or packaging far apart on different workstations. All items are then assigned with a unique location code. The labels will be generated at preset printers according to the location of the drugs. Issuing Counters Diagram 2: Integrated Inpatient &Outpatient Section Results If a separate working store is to be set up for inpatient dispensing section and all the nonparenteral preparations are stocked, then the number of item-locations kept in integrated section versus that in separated section is shown as follows: Number of Items Separated section Integrated section Less number of item-locations The integrated section reduces the store management workload such as stock replenishment, expiry date monitoring by about 50%. In addition, less holding stock is required in working store because there is only one location per item. Less replenishment 1384 934 450 activities will also reduce certain dispensing errors which are caused by mistakes in replenishment. Since the two sections are integrated right from the start, we do not have any data of dispensing error for separated sections for comparison. With the present setting, the average waiting time for outpatient prescriptions is maintained within fifteen minutes except for those require further clarification. For the inpatient section, the medication administration records are usually processed within one hour. Our pledge to complete the refill prescriptions for inpatients before one o’clock in the afternoon can always be achieved. Discussion The significant reduction in item-locations relief the stock management workload and achieve a better stock control. The manpower saved can be deployed to other value added activities. One main extrinsic factor to the success of the integration of the inpatient and outpatient dispensing sections is the distribution of workload of the two sections. The peak workload period for inpatient is in the morning as the ward rounds by doctors normally start in the morning. Most computer data entry of patient’s medication profile and dispensing of refill medications are done in the morning. On the contrary, the peak workload period for outpatient is in the afternoon when most of the specialist outpatient clinics operate. The proximity of the two sections also allows flexibility in deployment of staff. For example, during lunch hour and between six to seven p.m., only three staff are sufficient to manage both sections. In addition, all dispensing staff are fully aware of the labels generated from any of the printers and will perform the dispensing promptly because of the nearness of the two sections. The operation with one team of staff also has other intangible benefits. The workload is evenly distributed among all staff and the possible discontent arise between two teams can be avoided. The dissemination of information is more efficient and all staff are well informed of policy changes. The training and rotation of staff are more efficient and they are usually well trained within four weeks. The supervision is also more effective because of the proximity of the two sections. Conclusions The integration of the inpatient and outpatient dispensing section results in a more organized and efficient workflow arrangement. The peak and trough workload of the two sections is well matched so that the staff can be deployed timely to achieve the maximal throughput. As a new pharmacy department without any burden of norms, it is easy to cultivate our own culture that there should not be any distinction between the two sections. As a result, our goal in providing service with quality and efficiency is achieved.