The benefits of the collaboration between Deenova and ASST Papa Giovanni XXIII in Bergamo are the focus of Farmacia Ospedaliera‘s interview with Michela Franzin, director of the hospital pharmacy at the facility.
High-tech is spreading in the Pharmacy of Papa Giovanni XXIII
Papa Giovanni XXIII Hospital in Bergamo is a case of excellence and foresight in terms of technological evolution, as evidenced by the introduction of robotics in the pharmacy
Author: Viviana Persiani
The process of robotization through innovative digital technologies has also affected the healthcare sector, offering a substantial contribution in terms of effectiveness, efficiency, precision, safety for both patients and staff, as well as in terms of waste reduction. Among the examples of excellence that have taken the first steps toward technological evolution, the ASST Papa Giovanni XXIII in Bergamo has introduced robotics in the hospital pharmacy. Dr. Michela Franzin is a witness to the automation process of the ASST Pharmacy, which she now manages. “The process of robotizing the Pharmacy of Papa Giovanni XXIII Hospital began in 2006, introducing the computerized prescription and preparation system for drug therapies, extending it to the wards, outpatient clinics, and day hospitals, excluding the Emergency Department and Critical Care, where alternative solutions were adopted. The next phase of robotics implementation involved the logistics system for medications and medical devices, and more.”
Automatic AGV handling
For a hospital that manages the daily transport and movement of tons of materials, including waste, meals, linens, as well as medications, some more urgent than others, blast preparations, compounded drugs, and medical devices, automating logistic flows was necessary. Today, movements occur on rails with a heavy automated transport system using automatic AGV handling, ensuring a high level of hygiene, material integrity, and a significant reduction in turnaround times.
Central warehouse cabinet
To ensure the quality of care, safety, and appropriateness of pharmacological therapy, a cabinet was placed in the central warehouse to manage unit-dose medication. The goal was to facilitate the logistics of personalized therapies to various departments up to the patients’ beds. This last intervention affected all the inpatient departments. Some of them were assigned a couple of cabinets from which medications could be dispensed by drug class. Here, the unit dose is packaged in sachets. “Thanks to the hospital’s computerized prescription, the cabinet’s management software allows for the automated loading of the trolley with the requested therapy, present in unit-dose sachets, with all the essential drug identification elements placed in drawers set up and dedicated to individual patients. These therapies are entirely traceable from origin to administration. The adoption of this system, with the availability of unit-dose medications, reduces distribution errors, ensuring patient safety. Unit-dose allows for the tracking of the care process. Additionally, thanks to the software, cabinet inventory, incoming and outgoing flows, and supply can be recorded coherently.” Unit-dose medication is prepared externally by a contracted company. “The ready unit doses are brought to the pharmacy, and the service involves loading them into the cabinets according to prescription requests. The company itself monitors their availability every day, replenishing them as needed”. In 2012, when the transfer from the Bergamo Ospedali Riuniti took place, three tenders related to logistics were carried out.
Robotic automated cabinet
In 2021, a robotic automated cabinet was also installed in the hospital warehouse. “This operation stems from a feasibility study conducted in the second half of 2020, in which a large working group participated. Today, the cabinet contains 30,000 to 40,000 drug packages and on the outside, it has baskets, dispensing points that allow the assembly of baskets for the departments. Loading can occur automatically or semi-automatically (automatically through a hopper or in limited-size entrances used when the medication is first inserted). The centrally organized system, introduced at the end of 2021, also made it easy to manage lot activity, such as retrieval from departments for any anomalies reported by the Ministry of Health, as a precautionary measure. At the same time, a pharmacy warehouse activity management procedure was initiated, in which the picking list system was introduced. When a request for replenishment is received from the departments, it is split between the products in the cabinet and those outside. The cabinets have a capacity limit in terms of quantity and quality: for example, refrigerated medications are not allowed, nor are medications that cannot fit for volume reasons. For the size of Papa Giovanni XXIII Hospital, more would be needed. The robotic cabinet brings significant advantages, such as reducing manual loading and unloading errors, allowing for a clear reduction in inventory times, eliminating differences between accounting and physical inventory, monitoring inventory in terms of quantity and value, as well as expiration dates, and simplifying the retrieval of lots reported by the Ministry of Health. Additionally, the automated preparation of baskets for the departments facilitates accurate reporting in the company’s management system: loads and unloads are instantly recorded, and the optimization of reorder activities has allowed staff to acquire greater expertise through adequate training in the use of the software in the robotic cabinet, reducing resources dedicated to preparation.” The robotization process has improved the internal operation of the pharmacy, optimizing automatic activities that are susceptible to errors by personnel. “Nursing resources, supported by technology, can devote more time and attention to patient care.”
Pneumatic tube system
In 2021, a connection system was introduced between the pharmacy warehouse and the Discharge Pharmacy. At Papa Giovanni XXIII, there is a medication dispensing counter for discharged patients and patients with chronic conditions, authorized to collect medications with a bimonthly prescription based on periodic follow-up. “An important and necessary solution, but with some critical points. Since the Discharge Pharmacy does not have the ability to store medications, it was decided to create a single centralized pharmaceutical warehouse at the pharmacy to reduce assembly errors, have better traceability, and reduce stock that is difficult to locate because it is scattered throughout the hospital departments. Time was a key variable that promoted the adoption of pneumatic tube system, which is very fast from the moment of request to distribution. In a few minutes, the requested therapy is delivered by the pneumatic tube.” Pneumatic tube system has introduced further improvement: connections start from the cabinet to send therapy kits to the Discharge Pharmacy, reducing time and error risks compared to manual preparation.
Macro and micrologistics tenders: medications
“Last year, when the agreement with the companies that had contributed to the development of robotization at Papa Giovanni XXIII ended, we had to reorganize the macro and micro logistics system, trying to rationalize and harmonize the processes. The goal was to automate to reduce the activities of healthcare personnel and further improve patient and healthcare worker safety. We needed to redesign the tenders, splitting them between macro logistics and internal logistics, with particular attention to medical devices that are sent from the pharmacy to the department. For medications, additional automation was proposed. Before opting for a model, we conducted an analysis and submitted a report to the strategic direction, based on an evaluation of the cost of the service and the availability of new technologies. The final decision had to be shared with the corporate management of social healthcare professions, the political direction, the purchasing management, and the corporate quality manager. In agreement, the evaluation was carried out by a third party, a mini-HTA with the aim of evaluating whether the developed model was appropriate, based on the technological innovations available. The result of this analysis supported the choice of our solution. Despite an increase in service costs, automated transport has generated increased benefits in terms of costs and avoided hospitalizations due to therapeutic errors. The adopted system is advantageous, even in the long term, thanks to the reduction of logistical and operational activities of personnel, as well as for the containment of inventory and waste, consumption, and workload. This required further enhancement of the solution. Unfortunately, during the Covid period, optimization activities naturally slowed down. However, the system needed to be maintained and improved. Currently, we produce 1,265,000 unit doses per year, covering about 65% of administrations, excluding some medications that will never be in unit dose. Therefore, it is not surprising that the revision of the logistics and supply model is a key factor in improving efficiency and the quality of service to patients”. Medication administration errors, excessive inventory in departments, and obsolescence are just a few of the factors that impact the budget in healthcare logistics, affecting public spending and service quality. “The tender specification that expires in July includes the introduction of the latest generation of automated cabinets in departments for managing unit-dose medication, with the goal of managing loading, unloading, lot and expiration date tracking, and reducing nursing work. The automated cabinets will be installed in all departments and will be managed by a prescription drug system. Unit-dose cabinets, for example, will not be used in Pediatrics where standard drug formats are not used; however, the management of packaged medication will be chosen with the prescription drug system. For departments that do not use this system, such as those in the critical care area and the Emergency Department, a kanban system was introduced”. It is a simpler system and an effective tool used in healthcare logistics: the solution consists of an RFID tag that contains all the necessary information for restocking the reference item. “Once the tag is taken, placed at a critical threshold, it is inserted into a device from which the signal generates the connection, and the request for resupply is automatically initiated. To help optimize and contribute to the logistics activities of nursing coordinators in departments without the prescription drug system, kanban represents an optimal solution”. In the “medication” sector, the first phase of the tender has begun, which concerns the management of personalized therapies for detainees at the Bergamo prison, where there are issues, primarily due to a lack of qualified personnel. The project aims to adopt a management system similar to that used in residential care facilities. Today, daily therapy is delivered, but the goal is to reorganize, taking advantage of technology. The system provided by the Lombardy Region, which includes an electronic folder distributed to all prisons, with a prescription module, will be used. The project is still in the implementation phase and is not yet active: to generate unit doses, the system will need to communicate with the software.
Macro and micrologistics tenders: medical devices
In the process of organizational and managerial innovation in Healthcare Companies, as well as in hospital pharmacies, one of the proposed changes to ensure the safety, reliability, and efficiency of processes is the traceability of medical devices. “Regarding medical devices, the first tender for traceability of high-cost consignment medical devices was launched. Gates and cabinets were set up to trace the entry and exit of the product. With the new tender, we want to expand to include an additional gate and insert baskets in which the packaging of the device, once consumed, is discarded in the same basket and, through RFID, is read and linked to the reference of the procedure. It is a traceability system similar to that of medication and is also used for implantable devices”.
In conclusion, Michela Franzin mentioned, “In the near future, we have the ambition to automate the laboratory for the preparation of antineoplastic compounds inside the hospital. The process of preparing over 200 preparations a day is entirely manual, and the availability of a robot would provide safety, reduce turnaround times, reduce operator manual work, and offer some advantages in terms of waste prevention. Technology is progressing quickly, and we are already evaluating second-generation robots, which are increasingly efficient”.