BTW, all that quoting and /end quoting is tiring.
I'm off for a nap.
I just love my time off.
Take care,
Jeff
Jeff,
I would have responded last night, but I was letting you sleep
- j/king!
You're so much better with the scissors & paste, I can't even begin to quote you, but I will try to respond since you brought up really valid points.
For us - "boarded" pts are those that stay in the ER > 23 hrs. I'm not sure this is a global definition or one we just use (their med rec # gets changed @ the 23 hr mark from an ER to inpt #).
Actually - the two methods of electronic orders I've seen are physician input or non-physician. Both methods have urgency "tags" placed on them by the individual inputing the order before the final "enter". Physicians tend not to "tag" things too much....some nurses like certain things fast - narcotics & antiemetics for example - understandable.
For example...."stat = immediately", "now = within 30 min" and all other dosing - qd, bid, q4h without the modifiers are to be dosed within 1 hour (the assumption is they've never had the drug before) then picked up on the regular hospital dosing schedule. The problem here is - those medications the pt always takes....you have to specifically say - start in AM, or tomorrow, or hold today.....because the routine enalapril, furosemide, flomax...will all be dosed today (a source of drug error - so one that makes me initiate a call or visit to look at the pts history or talk to the nurse).
Now...take the example of that cardiac arrest that you resucitated & now have waiting for a bed. You gave the orders, the drugs have been administered & charted on the code flow sheet & now you're ordering the ICU orders & just waiting for a bed. You may order dopamine, an IV c K+, a diuretic, a narcotic, etc....but everything is already hanging or given because you've taken it from the code supply (which should easily be accessible by entering in pt Doe with an override & everything is available from pyxis). So...whoever is entering the orders in the ER computer will not tag them at all - so that tells me that they are to be available within the hour. I can then look at the date & time this person came & know if he/she has been here for longer than an hour....there really is no urgency - the drugs are still accessible. So...I'll make a call if I'm not in house or take a walk to the ER (just like I do when I get a new post op in the ICU) & ask the nurse in charge of that pt what they need & when. Hopefully, you're not bothered at all since you've moved on to another pt or many pts.
Now...take the example of the pt who needs streptokinase. Honestly - I'm usually called about this before the order was actually put in the computer (perhaps before it was actually written by you since you might have just said to call the pharmacy & get streptokinase) so I'm already putting it into the pharmacy computer system to be compounded. The only review I do is to make sure that my old drug records don't show an anticoagulant or antiplatelet that was ordered on a previous discharge that the pt might not have told you about & a quick look at the renal function labs. That data might not even be available yet, but that doesn't stop me from getting the drip ready for you. Beyond that - any other review can be kept for later from my perspective.
Finally, take the pt who you want in & out for a laceration. It took time to look at that cut, have someone clean it, either you or your PA stitched it & now you want Rocephin 1Gm before you send the pt home with rxs & instructions to see their pcp in 10 days. With the system I have, you put that Rocephin order in & tag it "now" - the computer notifies me, I look at the pts chart for allergies, age, wt if necessary & I enter it. It is available now in pyxis for the nurse to get befoe he/she has even printed out the discharge instructions. But.....again - very short stay pts can get drugs accessed without a prospective review just as your cardiac arrest pt - with an override & it is reviewed retrospectively.
It sounds really cumbersome, but its not in reality - but only if you have good software, which sadly is too often not the case.
But - & I guess this is my point....the hospitals, who pay for JACHO, want these upgrades & often cannot justify them without some external need. So...they can create the need by coming up with these mandates. How do you think hospitals afforded pyxis machines in the beginning? - exactly this way by JACHO not allowing the old "floor stock" med supplies without direct accountability. Pyxis is a more cumbersome process for pharmacy to be sure & nurses might agree as well. But - it is a reality because of many JACHO mandates.
Altho some pharmacists might say - you really need to have us be there 24/7 with you in the ER (misery loves company perhaps or a need to be needed???)....you know you don't need us there constantly (unless you have a really, really busy & big ER) & as docB said - we'd be in the way & underfoot. As much as we do have value & strive to be accessible, informational, helpful in avoiding drug errors....we are too expensive to add to the ER labor budget, which is already burdened with reimbursement issues. So - some kind of compromise is necessary to make the most of preventing drug errors without burdening the system or delaying tx & making your life more difficult.
I agree completely this is in many ways another way of "dumping" responsibility on to you folks and this will be a huge burden for those hospitals who still have the old fashioned paper orders that have to be taken to the pharmacy for processing. I also am a bit "bitter" about the "dumping" because that med reconcilliation & "do-not-use abbreviation" stuff has placed a huge & IMO unecessary responsibility on pharmacists (in addition to ER physicians) of reviewing medication based on unreliable data from pts or family & getting us to force order writing changes we rarely had issues with & were able to handle internally. But...the culture of those administrations is likely one that doesn't change or upgrade unless change is forced.
Anyway...thanks for listening, sorry for the length & hope you had a good nap & are enjoying your time off.
Who knows - perhaps the "perfect" system will finally be in place about the time we retire.
Have a good day!