Another Just Downright Awful Idea From JCAHO

[docB]

http://www.acep.org/webportal/PracticeResources/issues/jcaho/jcrxreview040907.htm

So their idea now is that every med order has to be reviewed and approved by a pharmacist. I'm fine with the review concept. My concern (and the concern of every EM related professional body) is that the time involved will cause long delays in getting meds to patients. They have some theoretical exception for "emergent" doses but they don't explain what that is or how it works. So as it stands we have been screwed by CMS and forced to meet their poorly thought out and medically dubious "core measures" which include "timely" administration of meds. Now we will be prevented from giving meds in any sort of timely manner because all orders will have to be reviewed prior to administration. Fortunately there's a group of docs who can just be thrown under the bus and forced to live with and take culpability for these *****ic schemes. Don't you love being an EP?

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[kungfufishing]

awesome sign me up! This is my pimp, Big Jay, he only charge 2 cigarettes.

 

[southerndoc]

I can see the next code:

EP: "Can we give 300 mg amiodarone?"
Pharmacist: "Is the patient on warfarin?"
EP: "The patient is in cardiac arrest for Pete's sake!"
Pharmacist: "You can give it, but I'm documenting this as a sentinel event!"

 

[Wackie]

Who is this JCAHO and why is he here?


Is this a required government thing or a committee hired by hospitals (I realize they like to go around and basically coach from the sidelines). And why is their opinion so important?

 

[southerndoc]

Who is this JCAHO and why is he here?


Is this a required government thing or a committee hired by hospitals (I realize they like to go around and basically coach from the sidelines). And why is their opinion so important?

Because most insurance, HMO, state, and federal reimbursement programs (Medicare, Medicaid) place a lot of emphasis on it. In fact, they often will withhold payments on those that are not accredited by the Joint Commission. So, no accreditation often means no pay. It's a huge deal to lose your accreditation.

 

[deleted77919]

I think now they are just called "The Joint Commission" I suppose because that sounds more evil and menacing, in other words more fitting for their role.

 

[Aloha Kid]

We have pharmacists evaluating all of our medication orders. My experience has been rather positive as they have caught a few allergy contraindications of mine. Although, true, you have to deal with the occasional censoring calls that impede you at times, the pharmacist have done an excellent job clinically keeping up with physician thinking. Yes, there are those rogue phramacist who really have become too good for their own good. They think they know everything about a patient by the medicine they take. Thank goodness I've met only one of these pharamacists.

The ER works a little different. We have urgent commonly used medications in our own pixus system in the ED. So ideally, the common stuff, pharmacy doesnt really bother us too much on. We have a dedicated pharamcist sitting in the ED reading through the electronic medication orders 12 hours a day. The past month they've been sitting right in front of me in my pod. I've run more questions by them than vice versa.

The hospital has also integrated clinical pharmacist into all of our ICU teams. For the most part these are really bright pharamacists who really contribute a lot to the managment of the patient and save a lot of costs with choice of abx, managing pharmokinetics properly, and keeping us updated with new indications of meds and proper usage.

 

[Febrifuge]

I think now they are just called "The Joint Commission" I suppose because that sounds more evil and menacing, in other words more fitting for their role.

I thought it was because every new rule they pass seems like it was fueled by a nice long, deep toke of the ganja.

 

[deleted87716]

I thought it was because every new rule they pass seems like it was fueled by a nice long, deep toke of the ganja.

 

[docB]

We have pharmacists evaluating all of our medication orders. My experience has been rather positive as they have caught a few allergy contraindications of mine. Although, true, you have to deal with the occasional censoring calls that impede you at times, the pharmacist have done an excellent job clinically keeping up with physician thinking. Yes, there are those rogue phramacist who really have become too good for their own good. They think they know everything about a patient by the medicine they take. Thank goodness I've met only one of these pharamacists.

The ER works a little different. We have urgent commonly used medications in our own pixus system in the ED. So ideally, the common stuff, pharmacy doesnt really bother us too much on. We have a dedicated pharamcist sitting in the ED reading through the electronic medication orders 12 hours a day. The past month they've been sitting right in front of me in my pod. I've run more questions by them than vice versa.

The hospital has also integrated clinical pharmacist into all of our ICU teams. For the most part these are really bright pharamacists who really contribute a lot to the managment of the patient and save a lot of costs with choice of abx, managing pharmokinetics properly, and keeping us updated with new indications of meds and proper usage.

I don't even have a problem with the oversight. That's not the issue. The issue is the time involved. It's great that you have a pharm in the ED. In my hospitals the "system" for dealing with this mandate will be too time consuming to deliver the med to the patient in anything approaching a timely manner.

For us it will be:
Doc write order
RN faxes oreder to pharmacy
Pharm approves order when time permits in between filling all the other ED and inpt orders.
RN gets fax from pharm
RN gives drug.

That will be as good as it gets. That's if there are no questions or problems. Also note that any fax will have some dead time while the fax sits on the machine waiting to be picked up and there will be some failed faxes so the order will get lost in the ether.

 

[SolidGold]

If the Joint Commission doesn't come up with a better solution, I think having a satellite pharmacy in the ED is what will have to be set up large busy institutions. I know Cinci has one, but I have to be honest because I don't know much about how it functions currently.

 

[DropkickMurphy]

I thought it was because every new rule they pass seems like it was fueled by a nice long, deep toke of the ganja.

Nah, it's just because the Trilateral Commission was already taken as a name.

 

[group_theory]

With the push for evidence-base medicine now, is there any evidence to show that the policies that JHACO puts forth (and requires) actually improves patient safety?

Also, JHACO isn't the only game in town. Believe it or not, the AOA does accredit some hospitals, and have since 1945. I wonder if JHACO continues to push paperwork and stupid ideas to the level that will make the Vogons look like a model of efficiency, if hospitals will choose to ditch JHACO and go with the AOA.

From the AOA's website:
http://www.osteopathic.org/index.cfm?PageID=lcl_hfovrview

The American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP) has been providing medical facilities with an objective review of their services since 1945. The program, which has also been accrediting healthcare facilities for over 30 years under Medicare, is recognized nationally by the federal government, state governments, insurance carriers and managed care organizations.

The AOA program has been granted "Deeming Authority" by the Centers for Medicare & Medicaid Services (CMS) to conduct accreditation surveys of:

Acute care hospitals
Hospital laboratories

HFAP is one of only two voluntary accreditation programs in the United States authorized by the CMS to survey hospitals under Medicare. The AOA has also developed accreditation requirements for ambulatory care/surgery, mental health, substance abuse, and physical rehabilitation medicine facilities.

The HFAP Alternative

HFAP is a recognized alternative to accreditation by the Centers for Medicare & Medicaid Services (CMS) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The laboratory accreditation program is a recognized alternative to accreditation by the College of American Pathologists (CAP) or JCAHO

 

[sdn1977]

docB - I feel your pain & I'm actually sorry you have such a cumbersome system....time for an upgrade!

The current state of the system is there is a pharmacist either in the ER or on-line...which means easily accessible (not by fax) & your orders are electronically sent & we get "triggered" as soon as you send the submit button - not handwritten, needing to be "taken off", faxed to a place & wait for someone to look for them.

Many hospitals do this, even with closed pharmacies at night by having a remote pharmacist at home look at all the ICU/PICU/NICU/ER orders so there aren't a ton waiting to be looked at in the morning. Its fairly easy with a system upgrade to the software (cost $$ though).

Oh - and yes....JCAHO changes have documented errors prevented & $$s saved for that individual who asked. It just cumbersome to do sometimes.

docB - the one thing that will "save" you - is to have your pyxis order entry changed to "trauma drugs" or "ACLS drugs" or "PE drugs" & lump all of the possibilites together (not the CII or III's though)...what ever you want to indicate an emergent condition. Under these circumstances, they don't have to be reviewed by a pharmacist since it is assumed (& documented in the chart) that you or another independent practioner was there the whole time. Thus it falls within the 48 hour retrospective review window which is just a PIA for me since I now have to go find the chart in medical records or wherever you sent the pt.....

Your facility needs to spend some $$$ to upgrade their system software!

 

[NinerNiner999]

Lets see - 240 patients per day, 2-3 physicians on duty, 2 patients per nurse, 4 PA's and NP's, and one pharmD to prospectively review and approve each medicine order.... Hmmm...

 

[docB]

Your facility needs to spend some $$$ to upgrade their system software!

Yeah, but they won't. What they'll do is create some work around for the code drugs, TNK, etc. and the drugs that affect the core measures and everything else will just have to wait. That's the central problem with JCAHO. Everything they do is an unfunded mandate. Sure having a doc reconcile everyone's meds on every visit is a great idea. Sure having a pharm review every order is a great idea. Giving every patient a free cadillac and having prime rib for every meal would be great too.

 

[sdn1977]

Yeah, but they won't. What they'll do is create some work around for the code drugs, TNK, etc. and the drugs that affect the core measures and everything else will just have to wait. That's the central problem with JCAHO. Everything they do is an unfunded mandate. Sure having a doc reconcile everyone's meds on every visit is a great idea. Sure having a pharm review every order is a great idea. Giving every patient a free cadillac and having prime rib for every meal would be great too.

I don't want to talk about med reconcilliation - that truly is a ridiculous notion (oh - similar to the one about do-not-use abbreviations, which, btw they have backed down on ).

But....think about it - unfunded mandate, but since JCAHO is funded by the hospitals themselves....this is a perfect way to get what they want. Their software system does not integrate well with other depts & they are out of compliance...what is the hospital to do but go to the board of directors & say we need to uprgrade the software to get in compliance.

It worked for us many times. We wouldn't have gotten immediate lab work reported to the pharmacy had that not been mandated. We'd still be schlepping back & forth to chemistry getting the gent levels by hand.

It is a self-sustaining mechanism. A little here, a little there. Ultimately, you'll get real-time interface with a pharmacist anywhere in the hospital - not one sitting right there, which is not tremendously cost effective. (oh - I predict med reconcilliation will go the way of not-to-use abbreviations - but thats just me...)

 

[Jeff698]

Many hospitals do this, even with closed pharmacies at night by having a remote pharmacist at home look at all the ICU/PICU/NICU/ER orders so there aren't a ton waiting to be looked at in the morning.

I guess this is my problem with this treat-everyone-the-same policy (except radiologists who remain exempt from this...everyone knows how critical their patients are). Many, if not most, orders I've written in the ICU have not been STAT orders. They are scheduled, do it in the next several hours or every X hours orders. They're on admitted patients who don't expect to be released in an hour.

The orders I write (or give verbally quite frequently) in the ED are give-them-right-now orders. The ones that aren't are give-them-in-the-next-5-minutes orders. By definition, there are no give-them-in-the-next-hour-or-two orders. That doesn't give us time to get a pharmacist review unless we have LOTS of pharmacists dedicated to doing nothing but reviewing our medication orders.

Let's look at some examples of things I want started while I'm in the room for the first time examining a patient or within 10 minutes of me leaving the room.

ACS/MI patients: ASA, NTG (SL +/- infusion), Lopressor, Fentanyl. For our STEMI patients, I also need heparin and integrillin hanging and I need it damn quickly because our cardiologist are literally wheeling them off to the cath lab within about 10 minutes of activation. I'm damn sure not delaying activation of the lab so I can buy time for a pharmacist (as useful as it may theoretically be) to confirm that my order is appropriate.

Pain. People come to the ER when they can't stand their pain anymore. They want it gone quickly, not after someone else reviews their doctor's orders.

Pneumonia: DocB has pretty well covered this little gem. We're frequently pushing 4 hours by the time we get to see the patient, get their fr&$^$ing blood cultures and give antibiotics. We're now adding extra time.

Sepsis, meningitis, open joints, lacerations needing tetnus updates...

My point is that there are not enough pharmacists out there 24/7 to make this mandate a feasible reality.

Everyone else in the hospital (and government) loves to complain about the long waiting room times for the ER and tsk, tsk about how inefficent those ER doctors are. They have no problem overlooking how what they do DIRECTLY contributes to this problem. This drives me cucking frazy.

PCPs start sending their patients to us at 3:30 (the exact time when our waiting room explodes) so they can go home. They tell patients to come to the ER on weekends or any other time they don't want to see them. They send them to the ER for 'quick labs or imaging' overlooking the fact that when everyone sends their patients to the ER nothing is quick or easy.

Hospital teams drag their feet getting inpatient rooms cleaned and available for admitted patients. Floor nurses find all sorts of reasons not to take report. Consultants prioritize ED consults behind lunch.

'Quality' organizations add mandate after mandate that delay, prolong and generally back up our EDs.

Everyone is making the problem worse and then has the gall to call it an ED problem like they didn't contribute to it.

Any minute we're going to see JCAH pull a UK NHS stunt and impose penalties for ED times greater than 4 hours. Hell, we're doing good to get patients into a room in under 4 hours.

This pharmacist review just pisses me off because it's one more brick in the f*&ing wall that makes it harder for me to provide timely care to my patients.

Sorry for the rant but I'm about sick of everyone else telling me how to be 'efficient' while doing everything they can to slow me down.

GRRRRRRR!

Take care,
Jeff

 

[GeneralVeers]

JCAHO needs to die, burst into flame, and fall into the most garbage-ridden sewer imaginable, never to return and pester us with irritating mandates.

 

[sdn1977]

Feel better ? I understand your rant & your frustration....

But - look a bit farther at the requirements - the examples you gave are not intended for the "immediate" review required by the regulations - these are the ones which would fall out & be reviewed retrospectively (ie - me going to medical records/ICU/post-op surgical unit - wherever....)

These regulations are actually designed for those patients who "room" or "hold" or whatever your particular hospital calls it when you are now functioning like the ICU or med/surg unit because there are no free beds.

When a pt stays in an ER because no beds or nurses to staff those beds exist, they now have to function like a medical unit - not like an ER. Since you indicate you never have orders that "give in the next hour or two", this may not apply to you, but those orders & pts exist in many ERs.

Yes - before you go off on that rant - yes - med/surg units also have emergencies which require rapid response without pharmacist review. Thats why there are functions & more appropriately - pyxis "orders" in place which allow opening of the pyxis unit without a pharmacists order review.

So - see - everyone is not treated the same. Your true "emergent" patient is allowed to be treated just like you want - you give the order, the nurse gets the medications (& if your pyxis is well set up it only takes 1 order - ACS/MI for example, to get all the medications out). You never even know I reviewed the orders because that happens a day or two (has to be within 48 hours) after the time you actually saw the pt.

But...that pt who has been in for the 3rd time this month for migraine, or the hand laceration requiring a prophylatic antibiotic after suturing, the rape victim needing Plan B after you do your exam & social services gets contacted - if you have good electronic ordering software, I can be alerted electronically there is an ER order within seconds of it being entered by you or the nurse if I'm in the ICU, in the pharmacy or at home. It comes with date/time of admission, so I can see if this order is on a new pt or a "boarded" pt so there are lots of clues to the urgency without actually being there.

Oh - the reason the radiologists are on "hold" now with order review is that most of them actually do the order, drawing & administering themselves since there are not often nurses in radiology (altho this is changing) & techs can't give the drugs (usually IV medications).

Altho physicians can & do make drug mistakes, it is assumed the "cow is out of the barn" so to speak so there is no time for a review - just as in your examples.

The intent is not to delay pt care, but when there is a delay, to make the best use of it possible. And - unfortunately, yes, there are many, many drug errors in hospitals and some do originate in the ER, sadly.

Don't get me wrong - I think this is probably a good idea, but with bad implementation (ie a mandate), but as I said before....I think there are other forces behind some of what JCAHO does & its not always pt care. Hospitals that don't or won't upgrade their systems, like docB's, will have a hard time implementing this. If they can't afford a system upgrade, they probably can't afford the pharmacist FTE to staff sufficiently to get this done - thus it becomes a hindrance &/or everything will be classified as falling into the retrospective review category, which will just them dinged on review.

I dont, however, think this idea is without merit, as I do the med reconcilliation or the do-not-use abbreviations ideas are.

But....I appreciate your frustration & feeling like a whipping boy. Not to equate our jobs....but, can you imagine how frustrating it is for us to go thru all these charts & review each one? Aaaargh! Tedium doesn't begin to describe it.

 

[chimichanga]

Because most insurance, HMO, state, and federal reimbursement programs (Medicare, Medicaid) place a lot of emphasis on it. In fact, they often will withhold payments on those that are not accredited by the Joint Commission. So, no accreditation often means no pay. It's a huge deal to lose your accreditation.

The northern AZ hospitals ditched JCAHO, and are better off for it...No lost revenue (in AZ, you can have the state's blessing and won't lose any reimbursement $$). CMS is the way to go. Our (2) hospitals are considering ditching JCAHO.

I'm hoping this trend continues nationwide, and in 20 years, JCAHO will become defunct...Not sure of other state's regs though...

 

[TysonCook]

I agree with the above. My goal in life is to become a suit in charge of JCAHO and then burning it to the ground from the inside out. They really are a bunch of red-taped ba$*****.

 

[Jeff698]

Feel better ?

Yeah, a little. Thanks for listening/reading.

These regulations are actually designed for those patients who "room" or "hold" or whatever your particular hospital calls it when you are now functioning like the ICU or med/surg unit because there are no free beds.

While the people writing the regulations may intend for them to apply only to those patients who are boarded in the ER and thus getting scheduled medication orders, I don't see where/how the distinction is made between boarded and non-boarded patients.

So - see - everyone is not treated the same. Your true "emergent" patient is allowed to be treated just like you want

Again, I'm note sure how this distinction is made. I also get nervous when someone else is determining who is and isn't an emergent patient. We've all seen how well insurance companies make that distinction. I don't think anyone can or should be making that decision who isn't the patient's on-site physician.

But...that pt who has been in for the 3rd time this month for migraine, or the hand laceration requiring a prophylatic antibiotic after suturing, the rape victim needing Plan B after you do your exam & social services gets contacted - if you have good electronic ordering software, I can be alerted electronically there is an ER order within seconds of it being entered by you or the nurse if I'm in the ICU, in the pharmacy or at home. It comes with date/time of admission, so I can see if this order is on a new pt or a "boarded" pt so there are lots of clues to the urgency without actually being there.

No offense, but I'm not comforted that you or one of your collegues, sitting upstairs in the ICU or at home, have lots of clues about the urgency of my order. You have no idea what else is going on in the ED. You're not there. That laceration or migraine patient, no matter how non-urgent they may seem, still needs to get in and out of the department as quickly as possible because that bed is needed for the chest pain patient who comes in shortly after they did.

This is exactly the point that I was trying to make before. Emergency Medicine is not about taking care of one patient at a time. Any effort to help us by slowing down the incremental time (i.e. how much time it takes to care for any one patient, even if non-urgent) ends up slowing down the aggregate time. This backs up the department and lengthens the time to be seen and cared for.

You mentioned one of your clues was the date/time of admission. Let's say you see orders on a patient who has been in the ED for four hours. Would you assume that this is a boarded patient?

Many of our patient's don't get back into a room within 4 hours. If they need a CT with oral contrast, they're going to be drinking contrast or digesting it for at least three hours. By then, using time of admission alone, they'd be a 'boarded' patient and medication orders would need prospective review. I just don't see how you can distinquish these types of patients.

The intent is not to delay pt care, but when there is a delay, to make the best use of it possible.

I have no doubt that that's not the intent. I'm sure the intent is to reduce errors. My point is that, regardless of intent, I'm afraid what will actually happen is that EDs will get even more backlogged.

Intent just doesn't get us very far.

And - unfortunately, yes, there are many, many drug errors in hospitals and some do originate in the ER, sadly.

Undisputed. I also don't object to assistance from pharmacy. I've worked with our clinical pharmacists on my in-patient rounds and have nothing to positive experiences to show for it. Our pharmacists respond to our trauma alerts and have been very helpful there as well.

If we really want to be helpful, put a full-time pharmacists in the ED 24/7. Don't tell me they can do the job just as well from home where it's more comfortable. Put them in the trenches with the rest of us, making real-time decisions right along with the rest of us.

Short of that, we're just making the problem worse with any form of prospective review. I have no problem with retrospective review.

But....I appreciate your frustration & feeling like a whipping boy. Not to equate our jobs....but, can you imagine how frustrating it is for us to go thru all these charts & review each one? Aaaargh! Tedium doesn't begin to describe it.

I suspect that it will be very frustrating. Crappy job, indeed, and one I'm glad I don't have.

Again, I welcome the useful assistance from my pharmacy collegues. I just think we need to be realistic about how we do it. We all know there aren't enough pharmacists to do it real-time in the ED and anything short of that is going to bog things down.

Take care,
Jeff

 

[Jeff698]

BTW, all that quoting and /end quoting is tiring.

I'm off for a nap.

I just love my time off.

Take care,
Jeff

 

[docB]

If we really want to be helpful, put a full-time pharmacists in the ED 24/7. Don't tell me they can do the job just as well from home where it's more comfortable. Put them in the trenches with the rest of us, making real-time decisions right along with the rest of us.

I agree with all of your points. On a slight tangent I would say that from a systems standpoint we might do better to have the pharmacist a little removed from the bedside. If they're right there they may get caught up in the chaos, emotion, urgency, etc. of the moment with the rest of us and not be able to add the detached analysis that I think we're looking for.

The real issue is that the cost of doing anything that would provide us with what JCAHO want would be prohibitively expensive. Paying 3-4 Pharmacy FTEs (full time equivalents = employees) to be in the ED or be immediately available to approve meds would be outrageous.

I can tell you that in one of the hospitals I work at the discussion is already revolving around haw to make the EPs liable for the whole process. The idea I have heard so far is to place language at the bottom of the order sheet where the EP signs that they, as the practitioner, have supervised every aspect of the med delivery. The question will be what constitutes "supervised." Clearly JCAHO wants it to be eyes or hands on throughout. The hospital is arguing that it means "in the vicinity of." Eventually, just like the med reconciliation, this will all get dumped on the EPs.

 

[IntheDraft6]

The system I work for is so paranoid about anything pertaining to JCAHO. When we get the transcription back for our dictation, they automatically attach a line that says, "I have reviewed the patient's medication history available at this time to the best of my ability and have reconciled any changes." It's an electronic transcript, but that is the only part that we cannot modify. Talk about having something forced on you. I guess there are ways around it due to some of the vagueness. I can appreciate the desire and thought behind these mandates, but the road to hell is paved with good intentions.

 

[southerndoc]

The system I work for is so paranoid about anything pertaining to JCAHO. When we get the transcription back for our dictation, they automatically attach a line that says, "I have reviewed the patient's medication history available at this time to the best of my ability and have reconciled any changes." It's an electronic transcript, but that is the only part that we cannot modify. Talk about having something forced on you. I guess there are ways around it due to some of the vagueness. I can appreciate the desire and thought behind these mandates, but the road to hell is paved with good intentions.

Isn't that illegal? If you didn't specify it in your dictation, then it is assumed you didn't do it instead of doing it.

 

[docB]

I'm telling you guys that is how this is going to go down. Just like every other idiotic JCAHO and CMS mandate it's going to be rammed down the throats of the EPs because we're the ones most easily bullied by the hospitals (because we're contract docs). Expect verbiage to be added to forms, dictations and discharge paperwork that says you have taken responsibility for these things, done them and attest that you did them. In my hospitals we're even being forced to do the pneumovax bit because they can't make the staff docs do it.

 

[sdn1977]

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!

 

[docB]

....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.

I didn't say that. I'd love to have a pharmacist in the ED 24/7. I love it when pharm comes to codes. It's easy to get 40 of Vasopressin. We were just having a discussion about how to dose Ca gluconate in a hyperkalemic and it was a big problem which would have been a non issue if we had easy access to pharmacy. The few times I have seen pharm down here it's been great. They ask "What are you trying to do?" I explain it and if it's appropriate they say "Write this." and then tell the nurse "OK, now you can give it like this." and everyone's happy.

....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.

That's my issue here. It's not that we'd get pharms in the ED. It's that I know we won't and we'll get stuck with some high liability work around.