Managing a health centre pharmacy: consumption, ordering and cold chain

Without adjusting for the stock-out, the ORS AMC would be underestimated (350) and the order too small (1,250), which would repeat the stock-out. Without removing the expired batch, no zinc would be ordered.

Months of stock = available stock / AMC: ORS 150 / 417 = 0.36 (about 11 days); artemether-lumefantrine 260 / 210 = 1.24; amoxicillin 2,000 / 1,200 = 1.67 (2.92 with the order in progress); zinc 500 / 260 = 1.92; paracetamol 9,500 / 3,000 = 3.17.

Order of urgency: ORS (risk of a new stock-out before delivery, to be reported immediately and, if possible, obtained as an emergency supply from the district), then artemether-lumefantrine, amoxicillin, zinc, paracetamol.

Expired batch: remove it from the shelves, place it in quarantine in an area marked "Expired, do not distribute", record it as an issue on the stock card (reason: expiry), declare it to the district and destroy it according to the national procedure. Find out why a batch went past its date: the "first expired, first out" rule was not applied.

Readings: 10 days x 2 = 20 expected; 18 taken (Sunday 05/10 missing); out of range: 3 (9.5 °C on the morning of 04/10, 0.5 °C on the morning of 07/10, -1.0 °C on the evening of 07/10). Compliant readings: 15 / 20 = 75%.

Probable causes: the power cut on the night of 03/10 explains the heat on 04/10; setting the thermostat "to coldest" on 06/10, in reaction, caused the freezing on 07/10.

Action to take:

• Excursion above +8 °C: check the vaccine vial monitor (VVM) on each vial; vials whose monitor has not reached the discard point can be used first; record the excursion.
• Negative temperature: risk of freezing for freeze-sensitive vaccines (for example vaccines containing tetanus toxoid or hepatitis B). Put them in quarantine marked "Do not use" in the refrigerator, immediately inform the supervisor and the district Expanded Programme on Immunization focal point, who organises the shake test of the adsorbed vaccines and decides whether to use or destroy them.
• Never change the thermostat to "compensate"; request a check of the refrigerator and the power supply.
• Assign a person for weekend readings and use a continuous temperature recorder (30-day electronic logger).

Adjusted ORS in September: 600 sachets, i.e. about 600 / 2 = 300 episodes of diarrhoea. Under the protocol, 300 x 10 = 3,000 zinc tablets would have been needed; 280 were used, i.e. about 9% of the need (and even with the 400 sachets actually given, 200 episodes, zinc covers only 14% of the need).

Zinc is hardly prescribed at all, even though it is in stock: the protocol is not being followed or there are recording errors. Proposals: check the consultation registers on a sample; discuss it with the head of the centre and the nurse; refresher on the protocol at a team meeting; job aid at the consultation desk; monthly monitoring of the zinc / ORS ratio. The zinc AMC will then be underestimated: the order will need to be revised if prescribing improves.

Example: "Subject: Monthly order and urgent points. Please find the October order: artemether-lumefantrine 580 blisters, ORS 1,518 sachets, zinc 540 tablets, amoxicillin 1,300 tablets; no paracetamol (3.2 months of stock). Urgent: 11 days of ORS remain; I suggest requesting an emergency supply from the district this week. A batch of 300 zinc tablets expired since 31/08 has been removed and placed in quarantine. The refrigerator dropped to -1 °C on 07/10 after the thermostat was adjusted: freeze-sensitive vaccines are in quarantine pending the opinion of the immunisation focal point. Zinc seems to be rarely prescribed compared with ORS: to be discussed at the meeting."