Controlled Substance Management/Pyxis Carts in OR?

[cchoukal]

So our pharmacy is putting some pressure on us to address some holes in our institution's handling of controlled substances (CS) in the OR. Too many "return intacts" and too many human hands on vials creates diversion risks, and so we're being asked to evaluate a few options. Has anyone used a good point-of-care accountability system? Pyxis makes a whole cart, with network connectivity for CS inventory mgmt, but it comes with a Pyxis cart, which doesn't look as big or customizable as we'd like. We also want to avoid inventory mgmt for non-CS meds and supplies.

What are you all using and what do you like/dislike about it?

Thanks!

---

Members don't see this ad.

 

[chocomorsel]

So our pharmacy is putting some pressure on us to address some holes in our institution's handling of controlled substances (CS) in the OR. Too many "return intacts" and too many human hands on vials creates diversion risks, and so we're being asked to evaluate a few options. Has anyone used a good point-of-care accountability system? Pyxis makes a whole cart, with network connectivity for CS inventory mgmt, but it comes with a Pyxis cart, which doesn't look as big or customizable as we'd like. We also want to avoid inventory mgmt for non-CS meds and supplies.

What are you all using and what do you like/dislike about it?

Thanks!

Why do you think you need a cart more giant than the Pyxis? It’s plenty big to fit supplies and drugs. And easy to use with your finger print.
Another company makes a cart too that I can’t think of, but it’s not as user friendly as Pyxis.

 

[deleted697127]

What’s the rationale for the massive expensive overhaul and administrative burden on implementing this? Less than 5 years ago, where i trained we all were walking around with a giant bag of drugs checked out and back in with an actual pharmacist. This was easy and worked.

After the Pyxis revolution, in every hospital I’ve worked at there’s been numerous burdensome systems under the guise of increased accountability all essentially requiring a random persons signature or fingerprint. I suspect the vast majority of people do not even care to look at what you’re wasting or returning.

My suspicion is that the pharmacists are frustrated with the increased time burden they are facing having to recheck in vials. Diversion risk? Please. I highly highly doubt they are worried about hands on a vial or someone cracking a vial and replacing the contents with saline and sneaking the cap back on. That sounds like a staffing issue for them, not a patient safety issue.

 

[deleted162650]

What’s the rationale for the massive expensive overhaul and administrative burden on implementing this?

It’s the VA. Standard Operating Procedure.

 

[cchoukal]

What’s the rationale for the massive expensive overhaul and administrative burden on implementing this? Less than 5 years ago, where i trained we all were walking around with a giant bag of drugs checked out and back in with an actual pharmacist. This was easy and worked.

After the Pyxis revolution, in every hospital I’ve worked at there’s been numerous burdensome systems under the guise of increased accountability all essentially requiring a random persons signature or fingerprint. I suspect the vast majority of people do not even care to look at what you’re wasting or returning.

My suspicion is that the pharmacists are frustrated with the increased time burden they are facing having to recheck in vials. Diversion risk? Please. I highly highly doubt they are worried about hands on a vial or someone cracking a vial and replacing the contents with saline and sneaking the cap back on. That sounds like a staffing issue for them, not a patient safety issue.

I pushed on this exact issue quite hard. Your experience in residency sounds eerily similar to mine, and I thought it worked great. At the same time, regulatory/oversight creep is real (often driven by corporations with a profit motive, no doubt). I'm told the whole UC hospital system (except UCSF, which is talking about converting) has already converted to this. Doesn't make it right, but it's hard to stand on ceremony when 100% of your peers are doing it. My ideal would involve NOT doing this, and instead some CS-only solution that would be mounted to our existing carts, for reasons related both to cost and ease, which is why I asked the group, hoping something like this exists.

 

[J Peterman]

If you must go the automated cart route, Pyxis >>>>> Omnicell and works well. Used it throughout training and now in private practice.

Do NOT allow pharmacy to settle for Omnicell units in the OR. You will (probably) hate them.

 

[MirrorTodd]

Pyxis everywhere I've rotated and they've worked fine. Customizations are in for specialties like cardiac surgery. Occasionally, I'll run into needing/wanting to use a drug that isn't stocked like ketamine in some carts or remi/sufenta etc. It's better than the system we had before which was checking drugs out of the core pyxis or in the preop/pacu area.

 

[abolt18]

Our hospital, we have to run to pharmacy between cases to get/exchange "a box" which has some midaz, some fentanyl, and some hydromorphone. Works fine but not efficient if you were trying to have fast turnovers (yeah right, they take like 45 minutes to turn over a room)

 

[MoMoGesiologist]

Our hospital, we have to run to pharmacy between cases to get/exchange "a box" which has some midaz, some fentanyl, and some hydromorphone. Works fine but not efficient if you were trying to have fast turnovers (yeah right, they take like 45 minutes to turn over a room)

Dealing with pharmacy counting my fentanyl and midaz and remi CCs was the bane of my existence as a resident.

 

[pgg]

We just blew untold $zillions on new Pyxis machines in every OR last year.

In a way it's convenient because we don't have a line at the central Pyxis any more. It works fine. Beyond the initial annoying learning curve of memorizing where everything was in the drawers, no complaints.

It's actually a lot more work for our pharmacy because now instead of one central location to restock, they have MANY locations to restock. But it keeps the leather undergarments the narcotics paperwork gestapo wear from getting in a bunch.

What a stupid way to spend money. But, speaking as an end user and not an accountant, the Pyxis machines are nice.

 

[nimbus]

We had the Pyxis anesthesia carts for a few years. I loved them because they made a nice high perch where you could sit and still see everything that was going on in the room. Sadly our pharmacy decided it’s not worth paying $500/month/cart to lease them. Now we have smaller Pyxis machines in most of our ORs. They’re fine too. Definitely better than waiting in line at pharmacy every morning to collect fanny packs or lock boxes you need to lug around.

 

[Aether2000]

One hospital I am in has a Pyxis in every OR (25), another has a Pyxis in 5 out of the 15 ORs and a central Pyxis, another has one central Pyxis for 4 ORs. The Pyxis is easy to use, fast (as long as you are not returning drugs) and easy to find (the screen tells you what drawer and pocket the meds are in for non single dispensed items).

 

[jwk]

We just changed to Omnicell carts in every OR system-wide. I hate the Omnicell system itself, especially the big units in pre-op/PACU but the carts aren't too bad. Definitely a learning curve, but we really like having all the controlled substances we need actually in the OR, so the workflow has improved.

Counting is easy - ours are configured and stocked with one and only one vial of a controlled substance in each slot - so the count is always 1. This has dramatically cut down time spent reconciling drug errors. We've set ours up so that the top three drawers contain all the controlled substances. The next drawer is all our routine drugs (roc, lido, ephedrine, etc.), and the fifth drawer is our emergency/lesser used drugs (labetalol, epi, steroids, etc.) Those two drawers mimicked our previous drug tray setup so what was previously in a routine drug tray is now in the routine drug drawer.

The bottom drawers of the cart are for anesthesia supplies, which our techs keep stocked. The carts are set up so that the techs can only open the supply drawers, not the drug drawers.

Stocking is a PIA for the pharmacy folks - but they were the driving force behind getting them, and it came out of their capital budget, not ours, so I don't feel sorry for them. My understanding is that they're absurdly expensive (multiplied by probably 100 ORs), but again, not my problem.

The worst part of the carts are the printers and scanner that comes with it. The scanner wand weighs about 2 grams, is easily knocked off, and doesn't work consistently. There is a label printer that is supposed to print colored labels with drug name and dose, pt ID, our name, expiration date/time, etc - all TJC compliant - but the printer can't seem to keep the labels in the right spot, so only half the info is on the label - and it doesn't print barcodes, so we still have to manually enter a lot of drugs into our EMR. There is also a separate printer that the pharmacists use for discrepancy reports. So two printers which are largely worthless AND take up about a foot of space on each side - so the cart width is nearly five feet, which is an awful big footprint in small ORs.

 

[DM27]

I've dealt with both the Pyxis and Omnicell in the OR and while I found the Pyxis to be better I think the automated systems are in general terrible. The pharmacy briefly tried to have us stock all medications into a dispenser (phenylephrine, etc). which I found to be a nightmare, I had more than one occasion where the machine chose to lock itself and seemingly do a firmware update when I was trying to take out another pressor during a case and had to call a colleague to get it from another OR. Whoever programmed it also added some irritating safeguards where if someone wanted to give hydromorphone during a case they needed a second attending/crna/resident to witness it before it would be dispensed. Regardless of what you get, make sure your department is involved with its setup and protocols.

 

[NoodleIncident]

My facilities include both Pyxis and Omnicell and I have no preference of one over the other with one exception. I have found my Omnicell off/resetting itself in the middle of the night when I needed it for a stat case. I then had to run to another room to grab my medications.

The problem that both of these have vs checking out a drug box lies on the anesthesiologist. The doctor is supposed to scan/check out drugs when they pull them. However many people don’t and when you go to pull a vial of Ephedrine, the machine thinks there are 5 remaining when in actuality there are none because the people in the room before you never checked them out in the computer. Pharmacy doesn’t know it needs to restock a medication if it doesn’t know that it’s running low.

 

[dchz]

Many of us who trained with Pyxis everywhere are shocked... WTF? you don't have every drug you need at your disposal in the OR? you mean i have to think ahead on what drugs i want to use??

Pyxis is great. Hated omnicell at the VA.

Has anyone noticed the drugs that aren't in the pyxis just gets used a lot less?

 

[vector2]

After using pyxis for a long time I got a job at a place that had omnicells. At first glance you think its gonna be really similar and then you realize you're actually drinking coffee from

 

[Steege305]

Give me a real pharmacist any day

 

[AdmiralChz]

I admit I had to look up what the difference is as I use both terms interchangeably in conversation.

Yeah we had the in-room Pyxis in fellowship. Once I got used to where things was (as a poster above said) I thought it was fantastic and having all the common cardiac drugs in one place was mega convenient and helped decrease waste as everything was basically right next to you. The major downside was a very depleted and short-staffed pharmacy staff had great difficulty keeping it stocked so every morning we had to go shop around for thinking’s like Milrinone or Dobutamine (especially when they went on shortage). I came away thinking it was a super expensive machine that requires a good amount of institutional support and if your place can’t provide it then sont

We have an omnicell system at my current shop and you do wastes/returns there as well with another person (RN/MD/CRNA), it works pretty well and since there are only a few of them around they are typically well-stocked. It can be annoying when someone dumps out all 25+ fentanyl vials and you have to count them one by one.

In residency we had Omnicells that spit out what you asked for in terms of narcotics and propofol (it was a controlled substance there). At the end of the case you returned it in a marked bag with a patient sticker. There were a LOT of miscounts/variations so I wouldn’t be surprised if this has now changed.

I think in a perfect world I’d prefer an in-room well-stocked Pyxis that is continuously replenished - assuming you had ORs large enough to account for the large footprint. Don’t bother with a printer if you can help it, I’ve only heard bad things and ours at the Va was like the McDonald’s ice cream machine - always down! Apparently there is technology to alert Pharmacy when drugs are pulled/are short in the system so they can come restock, but in today’s world of hospitals trying to run as lean as possible (in every except nursing administration that is) most places won’t want to employ extra techs to run around to a bunch of ORs multiple times of day.

I think the “return in a bag” was the worst I’ve seen and has too much potential for abuse.

I have not seen the in-room Onnicells but the newer generation of these machines are actually pretty nice. Same caveat to the above with Pyxis would certainly still apply.