In an ASHP Midyear 2022 Clinical Meeting & Exhibition Management Case Study titled “Sharp Objectives—Planning for Successful Sterile Compounding Renovations via a Centralized Dispensing Model,” Erin Stanley, PharmD, MS, BCPS, sterile compounding and quality assurance manager, and Amy E. Braden, PharmD, BCPS, manager-inpatient pharmacy operations, from University of Louisville Health (UofL Health), described strategies for centralizing sterile compounding services during a pharmacy renovation project while maintaining regulatory compliance.

Sterile compounding renovation planning is a complex process that requires focused effort, strategic considerations, and continued process improvement efforts, according to session presenters. The challenge before UofL Health: to utilize methods in a multihospital system to provide minimal disruption in the provision of patient medications while ensuring sterile compounding compliance, optimizing workflow, and leveraging current staff during a pharmacy technician shortage.

To accomplish this task, the team at UofL Health built a workgroup consisting of pharmacy operations leadership, pharmacy procurement, pharmacy informatics and dedicated sterile compounding pharmacists, include representatives from multiple affected facilities. Assessment strategies, the presenters said, included reviewing historical usage data per facility, determining consistent batch print/fill times based on patient population/physician practice, and “valuing qualified staff.”

Product batch compounding records, they added, were standardized to a single electronic documentation platform, and inventory levels were established. A shared electronic health record allowed batches for the renovation facility to print at the site designated as the “central fill” location. Courier services were set for specific times each day to accommodate for product preparation/verification time and to allow ample buffer time for delivery between facilities.

Implementation of centralized sterile services occurred several months prior to the start of the sterile renovation project to allow for process optimization. The renovation facility standardized batch fill qualify times to mirror the central fill facility to allow ensure consistency. Staff at the central fill facility were educated on product differences resulting from facility practice and automation capacity. Dedicated sterile pharmacists at each facility gradually worked through batch items that should only be prepped at the “home” facility due to their hazardous nature, limited stability, or medication inventory.

Since both UofL Health facilities are 340b eligible, they said, a reporting system was developed to ensure inventory of medication was appropriately ordered and designated by the dispensing facility. The pharmacy procurement team managed all inventory needs to allow frontline staff to focus on accurate product preparation and verification.

Additional measures, they said, were undertaken to ensure a successful renovation. Printing patient-specific batch labels at a single facility, for example, allowed for centralization of a considerable volume of sterile product needs. Also, moving batch product three times daily provided an effective method to accomplish a successful cleanroom downtime and allowed for valuable insight into the journey of developing centralized sterile compounding services.

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