ASHP guidelines on perioperative pharmacy services

Historically, pharmacy involvement in perioperative areas primarily consisted of providing medication stock for access by operating room (OR) staff, confirming appropriate storage conditions, checking expiration dates, submitting billing, and maintaining controlled substance accountability. In the early 1980s, pharmacists recognized the need for increased involvement and OR satellite pharmacies began to appear, particularly in academic institutions.1 Even so, the focus remained primarily on medication distribution and regulatory compliance. Evolving standards from regulatory and accrediting agencies as well as the need for improved charge capture and greater controlled substance accountability over the last decade drove increased pharmacy involvement in the perioperative medication-use process. Ongoing rapid changes in healthcare now demand that our attention be turned toward incorporating additional activities, such as supporting institutional quality and safety goals, developing perioperative treatment algorithms and order sets, and collaborating with the perioperative team to provide patient-centered, medication-related care in inpatient and outpatient settings. Finally, the challenge of cost-effective perioperative medication use has never been greater, with the movement from fee-for-service payment to value-based payment systems. In 1991, the first ASHP Technical Assistance Bulletin on Surgery and Anesthesiology Pharmaceutical Services was published.2 It was revised in 1998 and published as the ASHP Guidelines on Surgery and Anesthesiology Pharmaceutical Services, and it was reviewed without revision in 2003. This updated guideline is intended to provide guidance to health systems on perioperative pharmacy services. Two levels of perioperative pharmacy services are described: essential services, which should be in place in every healthcare setting; and desirable best practices, which must be tailored to the changing demands of healthcare, specific needs of the institution, and available resources. Services to perioperative areas as well as to procedural areas may be provided from an OR satellite pharmacy but may also be provided from a central or other satellite pharmacy location. While an OR satellite pharmacy with dedicated staff facilitates the development of the specialized expertise and close collaboration with OR personnel, these guidelines are intended for any pharmacy serving the areas noted above. Some or all of the services described may be provided by a dedicated perioperative pharmacist, a management or leadership-level pharmacist, or other pharmacy staff. Pharmacists may also use telepharmacy when suitable to remotely verify sterile compounding verification, pre- and postoperative medication order review, interactive postoperative patient medication counseling, or provide drug information to a facility that is geographically isolated.3 Consequently, the terms pharmacy, satellite pharmacy, perioperative environment, and perioperative pharmacist are used in the broadest sense. To understand and optimize the unique role of the perioperative pharmacist, significant differences found in the perioperative environment must be recognized, specifically the following: The medication-use process is fundamentally different from that in the patient care unit. Medications are administered by anesthesia care providers (ACPs) (anesthesiologists, certified registered nurse anesthetists [CRNAs], and anesthesiologist assistants), surgeons, others (e.g., perfusionists, physician assistants), and, very rarely, nurses. Medications are almost always administered by licensed independent practitioners such as ACPs or surgeons. A significant proportion of medications are high-alert medications. Medications may be used for off-label indications or administered by routes with which pharmacists may be unfamiliar. Multiple unique documentation systems exist within the perioperative setting. Medications administered by the surgeon are typically identified by the individual surgeon’s case-specific preference card, requested and obtained by the circulating nurse, placed on the sterile field, and administered by the surgeon or physician assistant as needed. There is often no pharmacist review prior to administration, particularly for commonly requested medications such as local anesthetics and topical hemostats. Some medications may be time sensitive, with reliance on verbal communication if the patient requires rapid intraoperative intervention and the surgeon is scrubbed in with his or her full attention on the patient. Pharmacy oversight in the OR may be complicated by medications, glues, and other agents in supply kits, which may be acquired through OR purchasing or a centralized supply department. Medications administered by ACPs differ from those used by surgeons, with few exceptions (e.g., local anesthetics). ACPs are typically the only practitioner involved in the entire medication-use process—prescribing, formulating and preparing, dispensing, administering, and monitoring the medication. 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