Issues with Pharmacy

[zdogg790]

Here is a situation that happened to me today. I work at a small community hospital (3 MDs, 6 CRNAs). I arrive at work at 11 AM because I am on call and I immediately head back to one of the ORs to give a CRNA lunch. While I am giving lunch, the Director of Pharmacy comes to our office looking for me so I can sign-off on some new policy. The CRNA that I am lunching tells her that I am giving him lunch and that I am back in the OR. She responds with "How can he be giving you lunch when he hasn't picked up his narcotic box from pharmacy yet?" This is when the s*%t hits the fan.

So I come out of the OR and am immediately summoned to administration where the Director of Pharmacy, the CNO (who I report to for some ridiculous reason, but that's another discussion), and our hospital compliance officer are waiting for me. The Director of Pharmacy starts immediately yelling at me basically saying that what I did is a violation of the Board of Pharmacy and that there is a "chain of custody" with narcotics that must be followed - that I cannot use the CRNAs narcotic box while he is at lunch. So basically pharmacy wants each anesthesia provider to carry a narc box on our person at all times and to swap out narc boxes during lunches and breaks. This seems a little ridiculous to the three of us docs. 99% of the time I never even open the narc box while giving a lunch. The CNO's solution was "maybe we should just stop giving lunches"....I'm not kidding. The Director of Pharmacy thinks the solution is an individual Pyxis in each OR.

What is anyone else doing with narcotics during lunches? I have never had this issue at any other hospital during training or otherwise.

Any thoughts/comments/suggestions would be appreciated.

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[JLM]

If the CNO says nurses cant eat, then nurses cant eat.

 

[Monty Python]

Here is a situation that happened to me today. I work at a small community hospital (3 MDs, 6 CRNAs). I arrive at work at 11 AM because I am on call and I immediately head back to one of the ORs to give a CRNA lunch. While I am giving lunch, the Director of Pharmacy comes to our office looking for me so I can sign-off on some new policy. The CRNA that I am lunching tells her that I am giving him lunch and that I am back in the OR. She responds with "How can he be giving you lunch when he hasn't picked up his narcotic box from pharmacy yet?" This is when the s*%t hits the fan.

So I come out of the OR and am immediately summoned to administration where the Director of Pharmacy, the CNO (who I report to for some ridiculous reason, but that's another discussion), and our hospital compliance officer are waiting for me. The Director of Pharmacy starts immediately yelling at me basically saying that what I did is a violation of the Board of Pharmacy and that there is a "chain of custody" with narcotics that must be followed - that I cannot use the CRNAs narcotic box while he is at lunch. So basically pharmacy wants each anesthesia provider to carry a narc box on our person at all times and to swap out narc boxes during lunches and breaks. This seems a little ridiculous to the three of us docs. 99% of the time I never even open the narc box while giving a lunch. The CNO's solution was "maybe we should just stop giving lunches"....I'm not kidding. The Director of Pharmacy thinks the solution is an individual Pyxis in each OR.

What is anyone else doing with narcotics during lunches? I have never had this issue at any other hospital during training or otherwise.

Any thoughts/comments/suggestions would be appreciated.

Just to arm yourself with first-hand information, call your state Board of Pharmacy for guidance and reference to a specific statute. What are your colleagues at other nearby hospitals in the same state doing?

We got rid of individual narc boxes, and now have one pyxis in the OR center core. Individual pyxis in each OR would have been better, but that request was denied due to money.

What are you currently doing with left-over narcs still in the syringe at patient hand-off to an anesthesia relief person?

You must try to have your hospital's organization chart redrawn to get yourself out of the CNO's lane. That's ludicrous.

 

[gasdoc77]

You must try to have your hospital's organization chart redrawn to get yourself out of the CNO's lane. That's ludicrous.

This.

It frustrates me to no end to see the bright individuals traversing the difficult road to be strong clinical anesthesiologists when this is the end game. As a hospital or AMC employee such is the pecking order. It wouldn't make fiscal sense for a physician to be dedicated to overseeing the OR full time, so nurses take the job. Try as we might to be involved, I am concerned that we continue to lose ground. Maybe the docs in Oregon are onto something.

 

[IlDestriero]

If they want individual pyxis machines in every OR that's your solution. Many hospitals have this, though it is very expensive.
There is no way you should be in the same chain of command as the nurses. That is ridiculous. My old small hospital had a surgical line and a primary care line that answered to the chief medical officer. The OBs were part of the primary care line. Lol.

 

[zdogg790]

You are all correct - it is garbage. I have had discussions with our CMO and COO about the fact that you have someone with higher credentials reporting to someone with lesser credentials. No one seems to care or see how this is an issue. My "boss" or CNO says things like "when you guys sleep patients..." It's like fingernails on a chalkboard. Yet here is this nurse who knows not one thing about anesthesia dictating what happens in my department.

I can only push this issue with my hospital so far because we do have a pretty good situation...well compensated, easy schedule, etc. Also, we were told that our administration met with Premier Anesthesia and have passed at their offer...for now. It's just really frustrating how low we are regarded at our hospital compared to our surgical colleagues.

Anyway, thanks for your insights.

 

[BobBarker]

This thread should be renamed "Issues with Anesthesiology".

 

[Yangkower]

You have 2 choices.
1. Enjoy your "good situation" and comply
2. Leave

You couldn't pay me enough (not entirely true but would have to be significantly higher than national average) to report to a nurse unless it was understood that he/she had no real power over me.

 

[chmd]

Why would an AMC be interested in such a small, rural hospital? Also how would they recruit your replacements if you didn't sign on with them?

 

[BuzzPhreed]

I can only echo the concerns with reporting line. I work for "the man" too, but we don't report to the CNO. Of course, ultimately we do all report to all members of the board of directors. But if I have a particular problem the CMO is the one who addresses concerns with the physician services. There are no line related process decisions made by the nursing department. This is micromanaging at its finest.

Next time when you give a break just have the CRNA take the narc box with them and leave you whatever was taken out and dedicated to that case. The "chain of custody" (if you will) is easily discerned. If there is a subsequent problem, it should be easily traced. Also remind everyone else on the board of the added time and cost (in terms of extra paper work and accountability) of unnecessarily checking out an additional narc box. This can be calculated by your time and the pharmacy tech's time in every instance that this has to be done, multiplied by the number of people and the number of times you have to do this each year. There are approximately 240 regular working days each year, and if this takes an additional half-hour of legwork and paperwork for each box you've just added 120 man hours of work each year, or an additional 3 weeks equivalent FTE per clinician for an unnecessary and resource wasteful request per year.

 

[deleted171991]

Why would an AMC be interested in such a small, rural hospital? Also how would they recruit your replacements if you didn't sign on with them?

Because, for these people, there is no such thing as too small, when about profit. Plus they want to claim geographical market share, like cellular companies with bad coverage. The only small hospital they won't want is a money-losing one.

Their plan, long-term, is also to extend from anesthesia to other specialties, so they will want to get a foothold as soon as possible, so that 5 years later they can say "look what a great job we did with anesthesia, now let us take over [another specialty]".

They are cancer, and they won't disappear unless outlawed. Which is exactly the way it should be: no private middlemen in healthcare. There is no value they bring, they just increase costs, same as private health "insurance" companies.

 

[Planktonmd]

If I were you I would focus on the director of pharmacy's solution to place a Pyxis in each OR, this is what many hospitals have done and it solves the issue.
As for fighting the nurses who run the hospital and expecting sympathy from administration this would be a very bad choice unless you are planning to leave soon.
Hospitals are run by nurses and accountants and they will tell you what to do for the rest of your career, the sooner you accept this reality the better for your mental and physical well being.

 

[jwk]

You can bet an AMC wouldn't be reporting to the CNO.

 

[Noyac]

You could take this matter of reporting to the CNO to the MEC. You have a medical executive committee don't you?

 

[Planktonmd]

You can bet an AMC wouldn't be reporting to the CNO.

Actually an AMC will do whatever it takes to strengthen their relationship with the hospital administration with complete disregard to what is better for the providers or the patients.
So, if the CNO is the one who runs the show in the hospital (which is the case in many small hospitals) the AMC will align it's policy with what makes that CNO happy and screw the providers.

 

[pgg]

Ugh. Don't tell that pharmacy admin weenie that you don't bother to put your initials, time, date, and concentration on the stickers on your pre-labeled syringes ... it's amazing how little your average pill-counting pharmacist understands about actual patient care.

If the CNO says nurses cant eat, then nurses cant eat.

LOL

Breaks are bull**** anyway, a wasteful misuse of manpower. Worse, they degrade the image of our specialty as they show us to be interchangeable cogs with no particular interest or duty to a patient.

When it's my turn in the barrel to make room and task assignments I follow the department culture of assigning 2 or 3 CRNAs to do nothing but give morning, lunch, and afternoon breaks, but I grind my teeth while doing it. It's a mindnumbing waste of manpower.

I hate giving breaks, I hate being responsible for someone else's anesthetic when I didn't make the plan. I hate proving to the surgeon that it doesn't matter who's in the "Hey Anesthesia" seat. I almost always refuse breaks when offered, but will accept for a pee break or a candy bar break in a looooong case. I'll stay an hour or maybe two past the usual quitting time to finish my case, then reluctantly accept relief ... I do have limits. But honestly, barring illness or late gravidity, everyone ought to be able to manage their bodily functions between cases.

The surgeons don't assign members of their departments to give breaks to each other during a gruelling gall bladder. They start and finish their cases. I've never understood why the anesthesia world has so much trouble doing this.

 

[BuzzPhreed]

I've never understood why the anesthesia world has so much trouble doing this.

Because we're often still working when they're in between cases.

 

[zdogg790]

Yes we have a MEC. That is a good idea...I will explore this tomorrow. Plankton, I suppose you are correct about accepting the reality of our situation. I will admit that it is hard to swallow. I have no intentions of leaving the hospital for family and geographical reasons, so I guess I should just suck it up.

I did call my state's Board of Pharmacy. They told me our current practice is perfectly acceptable (using one narc box during breaks and lunches), provided that the box is reconciled with a signature and time as each provider comes in and out of the room. This is what we pretty much already do. Believe me, I enjoyed relaying this info to our Director of Pharmacy...I think she was shocked that I actually called. Nothing like having to do my job AND her job.

In regard to the AMC sniffing around...I had the same questions about recruiting Anesthesiologists to our hospital...good luck with that. Apparently the AMC met with our COO and made an offer but he declined. This was all done behind our backs. Actually we had to find out from a surgeon who attends Board Meetings. Ridiculous.

 

[jwk]

Members of an anesthesia group or department need to be intimately involved in the governance of the hospital. Committees, board of directors or trustees, MEC, etc. that's the best way to know and have a voice in what's going on.

It's surprising to me that your department doesn't have "department" status. Our chief of anesthesia is on par with the chiefs of surgery and medicine in our hierarchy. We are not a division of another department, and obviously not under nursing which is positively absurd on so many levels.

 

[urge]

Here is a situation that happened to me today. I work at a small community hospital (3 MDs, 6 CRNAs). I arrive at work at 11 AM because I am on call and I immediately head back to one of the ORs to give a CRNA lunch. While I am giving lunch, the Director of Pharmacy comes to our office looking for me so I can sign-off on some new policy. The CRNA that I am lunching tells her that I am giving him lunch and that I am back in the OR. She responds with "How can he be giving you lunch when he hasn't picked up his narcotic box from pharmacy yet?" This is when the s*%t hits the fan.

So I come out of the OR and am immediately summoned to administration where the Director of Pharmacy, the CNO (who I report to for some ridiculous reason, but that's another discussion), and our hospital compliance officer are waiting for me. The Director of Pharmacy starts immediately yelling at me basically saying that what I did is a violation of the Board of Pharmacy and that there is a "chain of custody" with narcotics that must be followed - that I cannot use the CRNAs narcotic box while he is at lunch. So basically pharmacy wants each anesthesia provider to carry a narc box on our person at all times and to swap out narc boxes during lunches and breaks. This seems a little ridiculous to the three of us docs. 99% of the time I never even open the narc box while giving a lunch. The CNO's solution was "maybe we should just stop giving lunches"....I'm not kidding. The Director of Pharmacy thinks the solution is an individual Pyxis in each OR.

What is anyone else doing with narcotics during lunches? I have never had this issue at any other hospital during training or otherwise.

Any thoughts/comments/suggestions would be appreciated.

Can the CRNA go for lunch with his/her drugs and you stay drugless in the room? Can they give 50 of fentanyl before leaving? How much narcotics do you need during a break?

How does swapping narc boxes work?

 

[SouthSideSteve]

Because we're often still working when they're in between cases.

That would make sense if the surgeons weren't rounding/seeing consults/etc between cases as well.

I do see pgg's point. It always makes me smile when I see 3 different CRNAs during a case. I have noticed the residents take more ownership of their cases.

 

[BuzzPhreed]

That would make sense if the surgeons weren't rounding/seeing consults/etc between cases as well.

Pfft... Where do you work?

We strive for a twenty minute turn-around when the patient leaves the room. The surgeon often leaves the room a good 10 minutes before the case is over. I assure you they aren't seeing consults or rounding between cases. They're sitting in the physician lounge, maybe dictating their case, getting lunch, etc. Then, even when we push back for the next case, they don't show up until the patient is asleep and the patient is prepped. That's 40 minutes. On a good day. And, that's when we don't have to page them to show-up. (Only exception is when they're double-rooming, and even then their PA/CRNP is usually closing for them and they exit WAY before the 10 minute mark.)

I do see pgg's point. It always makes me smile when I see 3 different CRNAs during a case. I have noticed the residents take more ownership of their cases.

Well, you have a point there.