key: cord-0764584-xzxfnsp9
authors: Yeo, Yee-Ling; Chang, Chee-Tao; Chew, Chii-Chii; Rama, Shamini
title: Contactless medicine lockers in outpatient pharmacy: A safe dispensing system during the COVID-19 pandemic
date: 2020-11-17
journal: Res Social Adm Pharm
DOI: 10.1016/j.sapharm.2020.11.011
sha: 53add54a28908de296e39890c50d32e7cd37f348
doc_id: 764584
cord_uid: xzxfnsp9

nan

As of September 22, 2020, there was a total of 10,358 confirmed cases of coronavirus disease in Malaysia. 1 To combat the pandemic, one of the proactive measures by the Ministry of Health is to advise the public to avoid crowded and confined places. 2 In our hospital (Singapor General Hospital), the outpatient pharmacy serves an average of 1,000 patients daily during office hours. Dispensing medicines to outpatients has become more challenging, as pharmacy personnel are required to maintain physical distancing and avoid direct contact with the patients to prevent disease transmission in a confined waiting area. 3, 4 To reduce patients' waiting time and congestion in the waiting area, the pre-existing pharmacy value-added services were reinforced by the Malaysia Pharmaceutical Services Program, covering the needs of repeat medications supplies among patients with chronic diseases.These include: Prescribed Medication Courier Service, Pharmacy Appointment System, Drive-Through Pharmacy, and a Medicine Lockers integrated drug dispensing system. While different healthcare facilities may provide only certain types of services, patients were allowed to select theses serviceswhich suit their conveniences. 5 While all types of the value-added services are aimed to improve patients' convenience, most required some extent of physical contact. The medicine lockers dispensing service is the only mechanism which does not require the presence of a human medicine dispenser. In Netherlands, Koster and colleagues reported an increase in preference of using selfservice medicinal lockers in community pharmacies during the Covid-19 pandemic. 6 The Singapore General Hospital offers medication delivery service via secured locker boxes in designated polyclinics, where patients can receive their medications at any time and location at their convenience. 7 To our best knowledge, the medicine lockers dispensing service was not extensively described in previous literature. This letter discusses the operation, benefits and challenges of the medicine lockers service, which may serve as a safe and contactless mechanism to dispense medicines within a hospital setting during the pandemic outbreak.

The medicine locker dispensing service was first established by the pharmacy department in 2017. During the Covid-19 pandemic, the pharmacy department is actively promoting this service to the patients. Previous study reported that a physical distance of more than 1 metre can significantly reduce the risk of virus infection, and every 1 metre further in physical distancing leads to additional risk reduction by 2 times. 8 To ensure physical distancing, the lockers were strategically placed at the corridor beside the inpatient ward supply pharmacy, which is a less crowded area compares to the outpatient waiting area. Meanwhile, the waiting time in the outpatient pharmacy can be reduced by diverting the patients to use this value-added service. 9 Apart from the benefits of physical distancing, reduction of patients' waiting time may improve patients' satisfaction. 10 , which is indirectly associated with patients' acceptability of medication, adherence and clinical outcomes. 11 . Moreover,the medicine lockers dispensing service allows patients to obtain their medications at any period of time convenient to them.

The medicines lockers comprised of wood-made compartments with the dimension of 6" (L) x 6" (W) x 9" (D). Each locker is shared by 3 patients whereby every patient is assigned to a designated locker. They are given a period of 8 days to collect their supply of drugs from the lockers. The collection date is determined by the pharmacy, and each patient will be given a card together with the locker number after being enrolled in the service. The locker is installed with 3 sets of keys (A, B and C), where the pharmacy hold the master key and every patient who shared the same locker will be givenkey A, key B or key C. Throughout the 1st until the 8th of each month, only key A can be used to access the locker, whilelock B and lock C will be locked by the pharmacy with the master key. Patients who hold key B and C are not able to open the locker. Subsequently, from 11th until 18 th, only key B can be used while from 21st until 28th, only key C can be used.

In our hospital, there is a total number of 36 lockers, which can cater up to 108 patients. The service is available for patients who are on two or more long-term medications, excluding heat-sensitive and psychotropic-related substances, and patients who have cognitive impairment. Each time after seeing the physician, the patients will register themselves to be enrolled in this service at the outpatient pharmacy counter. The patients will be reminded on their medication collection date by using appointment cards.

In the pharmacy, medicines are initially labelled and filled by two different pharmacy staffs. The filled medicines are subsequently counterchecked by two pharmacists. The medicines are then placed in the pharmacy lockers by the pharmacy staff according to the schedule. To reduce the risk of pharmacy staff and patients exposure to the Covid-19 virus, the lockers surface are routinely disinfected using alcohol 70% by the pharmacy staff every time before placing the medications for the next patient. 4 Patients are requested to call the outpatient pharmacy in case of any discrepancies or doubts in regards to medication administration instructions.

There were several challenges when running this service. The labor capital required is greater than conventional face-to-face counter dispensing. To ensure medication safety, additional personnel are assigned to countercheck the medicines before keeping in the locker. Patients may not be able to check their medications or seek advice immediately in case of any discrepancies, although they were allowed to call the outpatient pharmacy helpline during office hour whenever necessary. Hence, experienced pharmacists were assigned to perform the final counterchecking task. No medication errors or discrepancies was reported till date as an outcome of this operation.

The medicine locker service is contactless in its operation, with theoretically zero waiting time, compared to the conventional face-to-face dispensing method, with an average waiting time of 20 minutes. This can minimise the risk of patient-to-patient transmission and patientto-healthcare workers transmission. Physical distancing can be easily maintained throughout the medicinal dispensing process. Apart from that, patients were allowed to collect their medicines over an 8 days period, available 24 hours a day without limited to officer hours. This alleviated the difficulties of patients getting a parking space during the office hours, and no additional costs were incurred to the patients.

The medicine locker service comes with several limitations. It may not be suitable for patients with a large number of medications, due to the limitations in locker size. Patients prescribed with heat-sensitive medications were not eligible for this service. Individuals with cognitive impairment, including elderly who have difficulties in remembering their medication instructions, 12 may find face-to-face dispensing method more suitable, as it can serve as a reminder to ensure medication adherence. 13 Currently, usage of the medicine lockers is relatively low as compared to other pharmacy value-added services. Realising its benefits, the pharmacy department is planning to expand the service by procuring more lockers. Active promotion through leaflet distribution and social media dissemination are also warranted. Each medicine locker which can serve up to 4 patients, was estimated to cost USD 15. With one hundred medicine lockers, this service can supply the medicines of up to 400 patients monthly. Given its cost and benefits, we believe that this service is affordable, safe and practical in health settings around the world, J o u r n a l P r e -p r o o f including developing countries which had less resources dealing with the socioeconomic outcome of the Covid-19 pandemic. 14 The medicine locker service had its benefits and shortcomings. Nevertheless, we concluded that the contactless medicine locker service is a safe and feasible method to dispense medications to patients, especially during the outbreak of highly contagious infectious disease such as the Covid-19.

From the Desk of the Director-General of Health Malaysia

COVID-19) in Malaysia. From the Desk of the Director-General of Health Malaysia

~:text=Physical distancing helps limit the,Protect yourself and others

COVID-19): Guidance for Pharmacies. U.S. Department of Health & Human Services

Pharmaceutical Services Program, Ministry of Health Malaysia. COVID-19 Infographic

Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies

Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis

Impact of value added services on patient waiting time at the ambulatory pharmacy Queen Elizabeth Hospital. Pharm Pract (Granada)

The Influence of Wait Time on Patient Satisfaction in the Orthopedic Clinic

Effectiveness and Cost Effectiveness of Pharmacist Input at the Ward Level: A Systematic Review and Meta-Analysis

A systematic review of medication nonadherence in persons with dementia or cognitive impairment

United Nations. UN/DESA Policy Brief #66: COVID-19 and the least developed countries. Department of Economic and Social Affairs Economic Analysis

We would like to thank the Director General of Health Malaysia for his permission to publish this article. We would like to thank Pn Normi bt Kamaruzaman, the Head of Pharmacy Department Hospital Raja Permaisuri Bainun for reviewing the content of this article.