drhemi70

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Hey all,
I am a pharmacist intern at a hospital this summer and the pharmacy and anesthesiologists here keep going back and forth on how best for the pharmacy to bill- supply the meds to the anesthesiologist.

We change something in the way we supply then next week one of them comes in and says how terrible it is. We change and then the next week another comes in say how terrible this way is.

We are using a high volume low volume tray system currently and we charge for all meds. Anesthesiologists do the wasting with the witness system by a nurse or other doc.

What are your opinions on pyxis in the OR with all the drugs you would ever need you just type patient name and withdraw what you need? Pyxis does the billing, and we do the waste when you replace what you don't use in the waste bin on the pyxis.

Just looking for some other ideas-opinions.
DR

ps it is a small hospital with 70 beds and 3 ORs
 

Laryngospasm

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drhemi70 said:
Hey all,
I am a pharmacist intern at a hospital this summer and the pharmacy and anesthesiologists here keep going back and forth on how best for the pharmacy to bill- supply the meds to the anesthesiologist.

We change something in the way we supply then next week one of them comes in and says how terrible it is. We change and then the next week another comes in say how terrible this way is.

We are using a high volume low volume tray system currently and we charge for all meds. Anesthesiologists do the wasting with the witness system by a nurse or other doc.

What are your opinions on pyxis in the OR with all the drugs you would ever need you just type patient name and withdraw what you need? Pyxis does the billing, and we do the waste when you replace what you don't use in the waste bin on the pyxis.

Just looking for some other ideas-opinions.
DR

Love the idea of the pyxis in the OR, in some ORs there might be space limitations, and it would be dificult to keep them stocked, seems like an expensive option. But it sure would be great to have a Pyxis right next to the anesthesia cart.
 

jwk

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drhemi70 said:
Hey all,
I am a pharmacist intern at a hospital this summer and the pharmacy and anesthesiologists here keep going back and forth on how best for the pharmacy to bill- supply the meds to the anesthesiologist.

We change something in the way we supply then next week one of them comes in and says how terrible it is. We change and then the next week another comes in say how terrible this way is.

We are using a high volume low volume tray system currently and we charge for all meds. Anesthesiologists do the wasting with the witness system by a nurse or other doc.

What are your opinions on pyxis in the OR with all the drugs you would ever need you just type patient name and withdraw what you need? Pyxis does the billing, and we do the waste when you replace what you don't use in the waste bin on the pyxis.

Just looking for some other ideas-opinions.
DR
if you're using pyxis just for narcs, fine. If you're using it to individually check out every single drug you have to use, it's a royal pain in the ass in an OR environment. I don't care how rosy the picture is that the Pyxis reps paint for you (they're wrong). I've heard of a few hospitals that have a pyxis machine in EACH OR. At $25k per machine, how is that cost effective?

We just went through this debate in our OR when we were having to buy a bunch of new anesthesia carts. The pyxis folks wanted us to use their machine as an anesthesia cart. What a friggin' joke! The instigator of this was one of our pharmacists, whose sole reason for doing this was to make her life easier.

Our pharmacy charges the patient based on what is written on the anesthesia record, and what's used and not returned out of pyxis. Having pyxis for charges in the OR is a way for the pharmacy to take the easy way out.

Besides that - if I need a certain drug, I need it now. I don't want to have to go into the damn machine each time.

Some places use a full drug tray that is signed out of pyxis - that's a little different story.

There are much better ways to deal with it than pyxis.
 
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drhemi70

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JWK,
How are your drugs supplied?

The problem we are having is that the anesthesiologist here want us to charge by the ml but (they don't like charging by the vial or ampule b/c of too much cost to the patient)then they don't write down what they use until the end of the day, I know pyxis wouldn't fix this, unless we change to charging by the vial.

One more question about working in an OR(I havn't and am just looking for advice). I have been told that when a procedure starts a drawer is opened after the patients name is entered and then all the anesthesiologist has to do is hit a button on the touch screen to access any med he wants in the tray. He takes out what he needs taps the screen to say how many he took and closes the lid to the cubie box and the main drawer stays open. Is this too much procedure for an OR?

Another problem we currently have is that there are two types of drugs in each pocket of the tray, and this is how the anesthesiologists wanted the trays set up so they wouldn't have huge trays. In this situation I feel the risk is high for grabbing the wrong drug, and am wondering what other hospitals and anesthesiologist have done to combat this problem?

Also to both who have responded. What are your procedures for wasting?
DR
 

seattledoc

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We have a pyxis in each OR. I was in doubt at first but now I prefer it. The controlled substances are in individual drawers, and you have to type the name into the keyboard to get them. The non-controlled drugs are in pyxis drawers that are like a regular cart. Once you are signed into the pyxis, those drawers are always open. It's never been an issue, not having an emergency drug immediately available. The selection is actually greater in the pyxis than it was in the old drug carts.
I'm not sure if we bill off the chart or by what drugs are pulled out of the pyxis under the patients name...
we need to have the OR nurse, attd anesthesiologist or another anesthesia resident verify by fingerprint when we return waste to the pyxis, this can be a pain but isn't bad. I've found most people go into the next-door OR where another resident is signed into that pyxis, find their patient on the system and "witness" their own return. Subversion at its finest!
 

Monty Python

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drhemi70 said:
Hey all,
I am a pharmacist intern at a hospital this summer and the pharmacy and anesthesiologists here keep going back and forth on how best for the pharmacy to bill- supply the meds to the anesthesiologist.

We change something in the way we supply then next week one of them comes in and says how terrible it is. We change and then the next week another comes in say how terrible this way is.

We are using a high volume low volume tray system currently and we charge for all meds. Anesthesiologists do the wasting with the witness system by a nurse or other doc.

What are your opinions on pyxis in the OR with all the drugs you would ever need you just type patient name and withdraw what you need? Pyxis does the billing, and we do the waste when you replace what you don't use in the waste bin on the pyxis.

Just looking for some other ideas-opinions.
DR
When JPP and I were at the same mid-Louisiana hospital, there was one pyxis in the OR center core, for 12 ORs. Usually worked OK, although at 0700 it was a royal pain when 12 anesthesiologists/CRNAs/SRNAs/RN circulators were impatiently waiting in line to use the one pyxis.

I've also had that machine give me the "blue screen of death" more than once, requiring a complete system re-boot. Not exactly what you want when the dantrolene is locked up inside.

This same hospital had no (none, nada, zippo) drugs in the anesthesia carts in the ORs. Apart from narcs which were individually supplied by the pyxis, the pyxis would dispense a single-use generic drug tray (adult, ped, or cardiovascular) containing enough of each type of med to do one typical case. We would put a patient name sticky in the tray, and pharmacy would charge based on what was missing.

Last time I worked locums at JPP's current hospital in January, 2004 (prior to his arrival) they had pyxis machine/cart in every OR. Didn't work with it long enough to form an opinion.

My current employer has all drugs (except narcs) generously supplied in each anesthesia cart. We have a pharmacy drug charge sheet in each pt packet, and we just put a tick mark next to each med used.

Each system has pros and cons. I do, however, prefer to not be dependent on a machine which can freeze, get stuck, have a long line, etc. I'm much more comfortable and efficient with a well-stocked drug drawer (per pharmacy or anesthesia tech) with me being responsible for marks on a charge sheet.
 

sdn1977

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As an OR pharmacist (part-time, yes...do time in ICU too), I find the pyxis a pain as well - far too time consuming for me!

We stock anesthesia carts. Each anesthesiologist has what they want which is defined to us by them....they can sometimes use just one room, or their preferences can define many rooms - we are flexible & variable depending upon when they work. So..we have quite a few specific cart spefications & have to look at the day they work, case they work, etc.... But...its easy - they aren't that variable - each anesthesiologist has their own "favorites" they like to have. We learn it & work with it - not that hard really.

They also get their narcs signed out to them in this fashion as well. We stock it in the evening & it stays locked until they get there in the AM, but after they get signed in - they are responsible for what's there. If they want to take some fentanyl to a stat call in their pocket - its ok with us. As long as they can document to the ml what they used. The circulating nurse is the cosigner for wastage. Unless the narc was used in an emergency...then we come (or the ICU pharmacist, unit pharmacist, etc..) to document what was used & sign what was left.

If there is no one particular person defined in a room - like the standby rooms - they are general carts. The Drs know what's on there & what's not. They know our phone # & call us from the room if they feel they need something & we bring it.

The pyxis is for the 24 hr call when we're not there. It is for the extra's after we leave or before we get there. It's an expensive machine to have in every room - but, if your facility has the money, they are getting a deal some place else...probably online billing I think.

Someone in situations like this always needs to have the ability to get past that "screen of death" you refer to. Pharmacists always do & nursing supervisors do for off shifts of pharmacists. In the OR....it needs to be someone....for us - all anesthsiologists have the pass keywords as well as the OR supervisors just so time does not get held up for machine breakdowns......otherwise....it defeats the purpose - which is to keep from "hoarding" medications in places we don't know about.
 

Skrubz

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our 3 hospitals all do it differently.

university: basic anesthesia drugs stocked in the cart (prop, etomidate, sux, roc, vec and all the other sundries) and narcotics come in a lockbox that you checkout at the beginning of the day. the "regular" (non-cardiac) box has an assortment of drugs (fentanyl, versed, dilaudid, morphine, demerol, cocaine, ketamine) and more special stuff can be checked out from the pharmacy separately (remi, thiopental). for wastage, we have a sheet of paper that shows what drugs we checked out in the AM and we just plop a patient sticker on it and note what drugs and what doses we use. there's a pharmacy sheet (carbon copy) in our anesthestic record that we also turn in so that everything can be matched up.

VA: basic anesthesia drugs stocked in the cart like at the big house, narcotics all in a pyxis in the central core. unfortunatley, only an MD can get drugs out of the pyxis, so if you miscalculated and need more drug, either you or your attending have to leave the room to get it. wastage is done at the pyxis with a witness. annoying.

county: anesthesia carts have most of the sundries but induction drugs, muscle relaxants and narcotics are checked out from a pyxis in the central core. bloody annoying. however, the circulators have access to the pyxis too, so they can get you more stuff in the middle of a case if you need. wastage used to be at the pyxis but now there's a box on the anesthetic record for wastage, which can be done with another MD or with a PACU nurse.

personally, i like the drug box, because when i need a drug, i'll have it handy. on busy days, you do have to head back to the pharmacy once or twice to check out more drugs (or just check out a bunch of extra in the AM). and i find it really annoying to have prop and muscle relaxants locked up in the pyxis. it also seems to encourage people to check out some extra "just in case", which ends up being charged to the patient (or the taxpayers at the county hospital).

as an aside, how does everyone access their respective pyxis machines? at the university (for afterhours cases when/if you don't have a drug box), there's a pyxis that we access with passwords. at the county, we've switched from passwords to biometrics (fingerprint scan) which i think is great because there's no more having to change your password every month or so.
 

jetproppilot

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trinityalumnus said:
When JPP and I were at the same mid-Louisiana hospital, there was one pyxis in the OR center core, for 12 ORs. Usually worked OK, although at 0700 it was a royal pain when 12 anesthesiologists/CRNAs/SRNAs/RN circulators were impatiently waiting in line to use the one pyxis.

I've also had that machine give me the "blue screen of death" more than once, requiring a complete system re-boot. Not exactly what you want when the dantrolene is locked up inside.

This same hospital had no (none, nada, zippo) drugs in the anesthesia carts in the ORs. Apart from narcs which were individually supplied by the pyxis, the pyxis would dispense a single-use generic drug tray (adult, ped, or cardiovascular) containing enough of each type of med to do one typical case. We would put a patient name sticky in the tray, and pharmacy would charge based on what was missing.

Last time I worked locums at JPP's current hospital in January, 2004 (prior to his arrival) they had pyxis machine/cart in every OR. Didn't work with it long enough to form an opinion.

My current employer has all drugs (except narcs) generously supplied in each anesthesia cart. We have a pharmacy drug charge sheet in each pt packet, and we just put a tick mark next to each med used.

Each system has pros and cons. I do, however, prefer to not be dependent on a machine which can freeze, get stuck, have a long line, etc. I'm much more comfortable and efficient with a well-stocked drug drawer (per pharmacy or anesthesia tech) with me being responsible for marks on a charge sheet.
I agree with Trin and JWK. Past/present job has ALL meds in pyxis.

Royal pain in the butt.

Much better IMHO to have stocked anesthesia carts with some other mechanism for controlled substances...the one I liked the best was a satellite pharmacy in the OR with a pharmacist there...
 
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drhemi70

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Okay ladies and gents,
Some more info so you will have a better idea as to what may be possible. I am at a 70 bed hospital with 3 OR. We have 5 anesthesiologists here, and it is difficult to get all the pharmacy people and anesthesia people together in one room long enough to sit down and get a policy in place. Don't get me wrong, we have something going currently, but nither pharmacy or anesthesiology are happy with it.

We currently send high/low volume tray down when doc calls for it, he keeps it until he calls for a replacement. In the mean time the doc uses the tray on multiple patients and we get five to ten different bill sheets for the patients that were done out of that tray down in the pharmacy. The bill sheets are supposed to be how we bill and how we maintain narc counts on the boxes-this doesn't work well for the pharmacy, because typically we don't get a sheet back in pharmacy that shows wastage and use for each patient, it is typically for the day or however the doc has the tray. This gets worse the longer the doc keeps the tray.

We would like to use single boxes and have patient billing and counts(wastage and use)/patient, or a day tray with all patients billing and usage/wasting. Docs say this would be a ton of paperwork and they won't do this. Docs also want their favorite anesthesiology med instead of a general box and us filling for what they individually need, so if we're going to supply a general box, it is going to be big to meet all thier needs.

In my original post I asked about pyxis and shouldn't have pushed so hard on that. What I am looking for from you fine people is how is it done where you are? What do you like,what don't you like? If you had your dream system in a 70 room hospital with 3 ORs and no chance of a sat. pharm what would it be? Keep in mind our state board requires accountability on useage and wastage, and we all want to keep our licenses.
Thanks for your time,
DR
 

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jetproppilot said:
I agree with Trin and JWK. Past/present job has ALL meds in pyxis.

Royal pain in the butt.

Much better IMHO to have stocked anesthesia carts with some other mechanism for controlled substances...the one I liked the best was a satellite pharmacy in the OR with a pharmacist there...
This is how it's done at my program (Univ of Chicago) and, after a month, I really like it. You can pretty much get anything you want in 10 sec from our very knowledgeable pharmacists and they take care of adding it to the billing form. We only keep track of/return the opiates and benzos (but obviously anything unused goes back as well, it's just not charted). As an intern, I rotated at a community ICU where all the supplies were pyxis-ized an it was a huge drag; I can only imagine what a drag it would be to deal with that every day for drugs.