Considerations for Automated Dispensing Cabinets (ADC) usage during COVID-19

The surge in hospitalized patients with COVID-19 has required substantial changes in protocols and workflow, including those related to the use of automated dispensing cabinets (ADCs). We asked Omnicell and BD Pyxis to help outline some considerations for ADC usage amid the pandemic. Their tips are listed below. Omnicell provided suggestions for preventing cross-contamination, securing COVID-19 medications (and personal protective equipment [PPE]), returning medications to the pharmacy, and maintaining safe practices. BD Pyxis provided a suggestion for relocating and redeploying ADCs in auxiliary patient care units, satellite locations, and field hospitals. (See an associated feature about refilling and cleaning ADCs in COVID-19 Frequently Asked Questions below.) 

Accessing the ADC

• When removing or filling medications at the cabinet, practitioners should follow a “clean hands” approach, performing hand hygiene before and after accessing the ADC. If gloves (only clean, never contaminated) are worn when accessing the ADC, they may interfere with the fingerprint scanner. You may want to consider disabling the fingerprint requirement (if state regulations permit) on specific cabinets or for specific users who might be wearing gloves, and instead require retinal scanning or entry of a username and password until biometric fingerprint identification can resume. If clean gloves are used when accessing the cabinet, they should be doffed and discarded before leaving the location, and hands should be washed.

• Store a container of the appropriate cleaning disinfectant nearby to allow those accessing the ADC to disinfect common touch points.

Decreasing traffic and limiting cross-contamination

• Consider temporarily increasing medication par levels (days of stock) to decrease the frequency of restocking and thereby reduce traffic to the ADC.

• Stock medications in multiple ADC bins with fewer doses per bin to minimize touch contamination of the bin by practitioners removing medications. To facilitate this change, review inventory reports to determine which medications are not currently used and remove them to make space for fast-moving medications.

• Secure as many medications as possible in locked-lidded bins or pockets, as this may reduce the risk of cross-contamination of other stock in the ADC.

Secure storage of critical items

• Consider keeping PPE locked in ADCs (or other locked storage containers) to control access and keep track of inventory.

• Consider placing medications in high demand, short supply, or requiring tighter control in locked-lidded bins; require periodic countback of those medications.

Returning medications

• To minimize the risk of errors and cross-contamination, never allow medications removed from the ADC to be returned to the specific bin or pocket from which they came. A common secure, one-way return bin should be used for returning unadministered medications to the pharmacy (including controlled substances), as long as they have not entered a patient’s room. (See additional details in a feature about returning medications to the pharmacy in COVID-19 Frequently Asked Questions below.)

Maintaining safe practices

• Require a documented (e.g., witness) independent double check by another practitioner when removing certain facility-defined high-alert medications from an unprofiled ADC or via override (bypassing the pharmacist’s review of a medication order to obtain a medication from the ADC when assessment of the patient indicates that a delay in therapy would harm the patient).

• Use ADC dispensing alerts to provide practitioners with critical information about new or unfamiliar medications, given that many practitioners may be working outside of their normal clinical practice area.

Redeploying ADCs

• When moving ADCs to a different location within the hospital or to a satellite location or field hospital, manufacturer-specific guidelines may need to be followed, depending on where the cabinet will be deployed. Contact your ADC vendor prior to moving a cabinet to ensure that any necessary guidelines are followed (BD Pyxis COVID-19 customer support; Omnicell COVID-19 customer support). Remember to rename the redeployed ADC to match the new location, and to stock it with carefully assessed and selected medications and par levels appropriate for the new area. 

COVID-19 Frequently Asked Questions

Question: Who is refilling and cleaning automated dispensing cabinets (ADCs) in areas where known or presumptive COVID-19 patients are treated, including the emergency department (ED) and critical care units?

Answer: Some hospitals report that pharmacy technicians are still refilling the ADCs in all areas of the hospital. However, a few hospitals report that nurses have been asked to perform this task. In one hospital, redeployed perioperative nurses have been trained to refill the ADCs as well as retrieve medications from ADCs for isolation nurses sequestered in patient rooms. During the refilling process, some practitioners also disinfect the ADC and barcode scanner while wearing personal protective equipment (PPE). Cleaning guidance is available from Omnicell, BD Pyxis, and the Environmental Protection Agency (EPA).  

Question: Are unused medications from COVID-19 patients being returned to the pharmacy?

Answer: Many pharmacies report that they are trying to dispense only the medications needed to minimize the volume of items that must be returned to the pharmacy. Several hospitals report that they are discarding all unused medications dispensed for presumptive and confirmed COVID-19 patients. One hospital reports that, regardless of the patient’s COVID-19 status, any unused medications that need to be returned are placed in a plastic bag labeled with the date and sent to the pharmacy, where they are stored in a secure, sequestered location. Then, after at least 3 days (the elapsed time beyond which viability of any potential SARS-CoV-2 virus on surfaces should be eliminated), pharmacists remove the medications from the bags and evaluate whether they can be restocked or should be discarded. No multiple-dose vials are returned to the pharmacy, as they are used for just one patient and then discarded. Also, no single- or multiple-dose formulations (e.g., creams, eye drop containers) of medications stored in a COVID-19 patient’s room are returned to the pharmacy. They are discarded (or sent home with the patient, as appropriate).