Should enteral formula be entered into my inventory as a drug or supply? If they are entered as drug orders, how do I separate them from my other pharmacy orders (because I have a special group of people that works on these)? It is not uncommon for a CPR+ trainer to be asked, “How should we handle enterals?” This article will review some ideas for managing this process as a drug/pharmacy process, or as a supply/HME process.

Tracking the Feeding Tube

CPR+ allows the user to track a patient’s access point for drugs and/or feeding tube via the Access popup on the Medical Info screen of Patient Demographics. The Access popup gives the user access to the Catheter Log, and stores all placements of access tubing. This is the first area that is suggested for tracking/recording a patient’s feeding tube. There are many forms in CPR+ on which the “Access” prints. Keep in mind, however, that CPR+ displays and prints the most recent access placement, so, if your patient is a multi-therapy patient, the feeding tube may not be the last entry.

The feeding tube may also be entered into the Comments field on the Order itself. This type of entry facilitates on-call research because the Comments field prints on the “On-Call Report.” Additionally, this information is available on the CPR+ Palm device under the patient’s Medication Profile. The Comments field is a free-form text field, so the pump may also be included in order to facilitate troubleshooting.

Enterals Entered as Drug Items

There are two, readily apparent, positive gains from entering enteral formula as a drug: 1) this facilitates lot number tracking, and 2) the enteral calculator may be used when creating drug orders for these products.

Lot Number Tracking

When formula is entered as a drug, the user has the option of tracking specific lot numbers, or just incoming quantities with costs. The obvious advantage of having the formula as a lot-tracked drug is lot number reporting. CPR+ contains a standard report “Lot Number Log / Report” that allows the user to obtain a list of drug lots dispensed for a specific date range and/or, perhaps more importantly, for a specific drug lot number. This report will allow you to find where your product is quickly in the event of a drug recall.

The disadvantage of tracking lot numbers for your formula is that you must put your trust in the warehouse staff to pull the appropriate lot number for the patient delivery. This can be tricky if you have large stocks of formula and the requisite lot number is at the bottom of a pallet. Additionally, this becomes somewhat of a hindrance if you dispense multiple flavors of product to your patients.

The Enteral Calculator

In Issue 10 of CPR+ Weekly Infusion, Jeff outlined the product setup on the Clinical Info tab of the Inventory item for an enteral product in order to use the enteral calculator. I will just quote him verbatim.

For Enteral products, On the Clinical Info tab, set the Dispensing Unit as ml, the Dispensing Units/Each as the number of mls per can, the Product Type as “Primary Drug” and the Dosage Form as “Enteral”. When you select the Dosage Form as “Enteral,” CPR+ will prompt you for the Volume/Can which is entered in mls and a “Kcal/ml” which you will enter based on the caloric value of the product.

With this information in place, CPR+ will be able to calculate the number of cans per day and per month you will need to dispense to satisfy the order, regardless of how the order is entered (“X” mls/hour x “X” hours per day, “X” cans per day, “X” cal/kg/day). To further clarify, the dose can be entered in Kilocalories or milliliters, the interval as any frequency in your frequency table – specified as “Continuous,” “Intermittent,” or “As Needed.” CPR+ will use this information to calculate the number of cans per day needed to satisfy the order and display the Clinical Preview.

Prescription Processing

The user may choose to fill the prescription using the IV format, if different flavors are being dispensed. This format includes a Compounding Record where, just like any other drug, multiple drugs of the same type (Generic Name) can be pulled to create the compound. This format will also create an NCPDP claim, but the claim will include one (1) line for each flavor included on the Compounding Record, or separate claims depending on how the Insurance Company record is configured.

The alternative to this is to use the PO format and just indicate the number of cans being sent. Note: the user can use the PO format for the purposes of creating an NCPDP claim for the total number of cans/units. The user may select the specific flavors on the Delivery Ticket (marked as non-billable, of course). This process allows lot number tracking to continue, for multiple flavors to be selected, and for the patient to see exactly what items are being delivered.

Enterals Entered as Supply Items

Let’s look at the organization’s structure for a moment. If your organization does not care to track lot numbers for formula, and, less importantly, your patients receive multiple flavors of product for a period; then, a better recommendation is to enter your formulas as supply items. “But, wait,” you ask, “how do I know what quantity to send unless I get my calculator out each month?” The answer is simple; create an HME/Supply Order with the number of cans per day (or month) in the quantity field – that leaves the Comments field open for tube and pump information. You can either use the specific formula to create the order, or create a Non-Inventory Billable Item in Inventory called “Enteral Formula and Supplies” (or something similar).

Now that you have the order entered, you can pull it on to your Working Delivery Ticket using the HME/Supply Orders (F6) function. This function will allow you to select the actual product being dispensed from inventory, or you can leave the generic description. The advantage here is that you can complete the quantity field for this item with the monthly quantity. Once this quantity has been established, then you can pull on the different flavors and disseminate the total quantity among the flavors. Remember that you can place a quantity of zero (0) on any line on the Working Delivery Ticket so that it will not print, nor deduct from inventory, but will remain on the Working Delivery Ticket for future deliveries.

The advantage to this methodology is that you can simply ask your patient, upon reorder, what flavors they would like. If they wish only Vanilla this month, then your entire quantity goes to Vanilla and the other flavors remain as options for future deliveries but do not need to be reselected onto the Working Delivery Ticket. This makes reorders a very simple process.

Final Notes

A final consideration on drug versus supply entry of enterals is the sequestering of these items from your other product lines. For those customers using the Enterprise List Manager, this can be accomplished by entering HME/Supply Orders and running these patients on the HME “side” of Enterprise. Remember that just because you have entered an HME order that you still have the ability to pull drug items onto your Delivery Ticket. These patient populations may also be filtered by assigning an Enterprise Team to them and filtering your Enterprise list by Team.

CPR+ also contains a function that will enable a “Supplies to Deliver Report” similar to the “Prescriptions to Compound/Deliver Report” for those customers not using the Enterprise List Manager. This report allows you to go to each patient and generate new Delivery Tickets for reorders (something that Enterprise does dynamically). As you can ascertain, there are many ways to handle your tube-feeding population within CPR+. If you have questions about best practices for your organization; why not schedule some time with one of our trainers? They can give you advice based on real-world experience.

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Columbus, OH      October 3-5, 2008

Are you burning with anticipation of topics to be covered at this year's CPR+ User Conference? Once again, the sessions offered will appeal to all CPR+ users at any level and job function. Several sessions will be taught more than once to make sure everyone has an opportunity to learn as much as possible about CPR+. As promised, we cover the latest changes in CPR+ and new CPR+ v8.1 functionality.

In addition to the standard two-day conference, we are planning to hold a full-day “Fundamentals of CPR+” seminar on Friday, October 3rd, as well as co-sponsor another Pre-Conference Reimbursement Seminar with Reimbursement Concepts. We’ll also have hands-on stations set up on Saturday where you will be able to meet our Customer Support and Sales Representatives and experience new features and products.

Click here to view or download the 2008 CPR+ User Conference Schedule.

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