The Michigan Difference

Hello everyone, my name is Adam Loyson and I am currently a pharmacy student at the University of Michigan entering my second year. For the summer, I am interning at the University of Michigan Hospital in multiple in-patient settings. While some of you might have read an earlier post given by Kari Horn who also works at the hospital, I will be providing you a different perspective outside of Mott Children’s Hospital where she is currently working.

With that said, I have started my training this past week by working in the central pharmacy department compounding medications. Particularly, I am involved with the mixing of various pharmaceutical compounds with different intravenous bases to create IVs for patients. While it is possible to make IVs in the satellite pharmacies located on each floor of the UofM hospital, most of the extensive and large batch production takes place inside the central pharmacy department located in the lower floor.

To make these intravenous medications for patients, I work in a area called the “Clean Room”. This area is considered very sterile and has a limit of less than 100 particles per square foot. Now that is clean! In order to enter the room, I am required to scrub with soap up to my elbows and gown up by wearing shoe covers, a medical mouth covering, a hair net, a full gown, and sterile surgical gloves with an application of sanitizer. Once in the clean room, there are five chemical compounding hoods that circulate the air in order to purify it. Four hoods are designated as regular pharmaceutical compounding while one is labeled for the production of chemotherapy drugs and is located in a separate room with even further sterilization requirements. Once gowned and ready to go in front of one of the hoods, I am required to sanitize my entire work area with isopropyl alcohol and keep documentation of such cleanings. I have learned that keeping documentation of cleaning, procedures used and inventory is very important quality control and in the case that hospital is investigated by the Joint Commission, which is the institutional body that accredits the hospital and is necessary for the acceptance Medicare patient insurance.

So let the fun begin! At designated times during the day, a batch of labels containing drug names and strengths are printed out. At that time, the labels are passed through into the hood and I am then able to start compounding the required medications. Attention to details is critical here as selection of the correct drug, the dosage strength, correct volume, correct procedure, and aseptic technique are all important. A sample scenario for compounding an IV medication would follow the following steps:

1. Selection of the correct pharmaceutical: Medication location in the clean room can vary based on chemical stability. Chemicals that are unstable at room temperature are kept in a fridge while chemicals that are sensitive to light are prevented from degrading by keeping them in opaque packaging. Finding the correct medication and strength that you need as designated on the hospital label is vital.

2. Dilution to the correct concentration: Most medications are supplied in the powder form for stability reasoning. In order for the drug to be added to the liquid IV base, it is diluted using saline solution, static water, or bacteriostatic water.

3. Drug Injection of the correct dose into an IV base: After dilution, a specific volume of the solubilized drug is drawn by syringe and injected into a base in an IV bag such as dextrose or sodium chloride. Selection of the IV base is dependent on each individual patient case and their disease state.

4. Compounding accuracy and delivery: Once the IV bag is finished and labeled, it is marked with a hang-by date and time, expiration date and time, as well as any special storage instructions for the nursing staff. The IV is then provided to a pharmacist along with the original drug container and syringe noting volume drawn to check for compounding accuracy. After it is verified, the IV drug is then ready for delivery to one of the multiple medication stock areas on each hospital floor called Omnicells that are kept under digitalized pass codes. This is where I get my exercise!

In summary, I had a blast this past week. If you are like me and enjoy doing labs in chemistry, compounding pharmaceuticals and creating individualized IVs for patients can be a rewarding experience. It gives me an excellent opportunity to familiarize myself with the drug names that are used by the hospital, special considerations for each medication, and a chance to brush up on my compounding bench skills. While this particular experience is specific to within the hospital's central department of pharmacy, I will be sharing my experience of working in one of the floor satellite pharmacies next week. Stay tuned as you have a great summer!