No more admixing by anesthesia

[Monty Python]

Two days ago the director of pharmacy came to our preop holding area. He promptly confiscated our bottles of 1% lidocaine to which we had added bicarb (and which is thrown away daily). He said "per new JCAHO rules, only the pharmacy is allowed to admix medications, and it must be done under a sterile hood."

Yesterday the OR schedule went nowhere, since at 0615 every single anesthesiologist and CRNA on duty faxed orders to the pharmacy for premixed syringes of ephedrine, neosynephrine, two STERILE syringes with heavy marcaine and duramorph (for scheduled c/section spinals), two bags of pitocin for the c/sections, four interscalene syringes with epi added to the naropin, etc etc. With just one pharmacy tech on duty, we didn't get our stuff until almost 0900 --- which caused exactly the reaction we wanted. There were several steaming mad surgeons in the CEO's office over this.

The pharmacist held his ground. So we warned him to expect a call at anytime day or night 24/7/365 to admix our pitocin/abx bag for a c/section. And he had better damned well respect the 20 response time that everyone in the OR has to abide by. THIS got his attention. Now he's "researching" the rules.

Just a heads-up, in case your pharmacy department pays attention to the new JCAHO rules.

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[PharmD2MD]

I am really glad I don't deal with this crap anymore. A few years ago, when I was still a practicing pharmacist, I tried to follow the JCAHO rules in a similar situation, but on a smaller scale. I knew the anesthiologist well, so he agreed to give it a try. It simply was not a workable situation, for the same reasons you mentioned. I just ignored this JCAHO provision from then on.

That pharmacist is probably still correct on the letter of the JCAHO rules. They are ridiculous and inflexible, but it is what it is. However, drawing a single ingredient up into a syringe isn't reallly admixing, so that should not be an issue. Maybe you can work on this definition with the pharmacist. I consider admixing when you are adding two or more ingredients to an iv bag or syringe, not simply drawing up a med.

One solution that I have seen work, is to have a pharmacist and a tech assigned to the OR in a little OR pharmacy, if they can spare the staff. Some of these things can be pre-made if the pharmacy has the proper clean room setup- that can save a lot of hassle. Basically, JCAHO doesn't want people outside of the pharmacy admixing drugs at all.

 

[dfk]

don't ask me how/when this developed, or how this will even work or be validated, but our chief research attendings said that before any neosynephrine is to be given to any patient at ANY time, they want a TEE done. i wonder where the line will start, how long the wait, and where the funds will come for the 20 or so of those that do/read TEEs.

 

[urge]

Two days ago the director of pharmacy came to our preop holding area. He promptly confiscated our bottles of 1% lidocaine to which we had added bicarb (and which is thrown away daily). He said "per new JCAHO rules, only the pharmacy is allowed to admix medications, and it must be done under a sterile hood."

Yesterday the OR schedule went nowhere, since at 0615 every single anesthesiologist and CRNA on duty faxed orders to the pharmacy for premixed syringes of ephedrine, neosynephrine, two STERILE syringes with heavy marcaine and duramorph (for scheduled c/section spinals), two bags of pitocin for the c/sections, four interscalene syringes with epi added to the naropin, etc etc. With just one pharmacy tech on duty, we didn't get our stuff until almost 0900 --- which caused exactly the reaction we wanted. There were several steaming mad surgeons in the CEO's office over this.

The pharmacist held his ground. So we warned him to expect a call at anytime day or night 24/7/365 to admix our pitocin/abx bag for a c/section. And he had better damned well respect the 20 response time that everyone in the OR has to abide by. THIS got his attention. Now he's "researching" the rules.

Just a heads-up, in case your pharmacy department pays attention to the new JCAHO rules.

I would welcome that rule, rather than bashing it. Pharmacy will get better prepared next time and stock drugs in a refrigerator. Change is good.

 

[Noyac]

don't ask me how/when this developed, or how this will even work or be validated, but our chief research attendings said that before any neosynephrine is to be given to any patient at ANY time, they want a TEE done. i wonder where the line will start, how long the wait, and where the funds will come for the 20 or so of those that do/read TEEs.

First, are you sure you understand what they really are saying? For example, A C/S under spinal needs neo. You need to drop a TEE in this awake pt having a baby and puking on you at the same time? THis is now the most ridiculous thing I've heard here.

 

[pgg]

Two days ago the director of pharmacy came to our preop holding area. He promptly confiscated our bottles of 1% lidocaine to which we had added bicarb (and which is thrown away daily). He said "per new JCAHO rules, only the pharmacy is allowed to admix medications, and it must be done under a sterile hood."

Yesterday the OR schedule went nowhere, since at 0615 every single anesthesiologist and CRNA on duty faxed orders to the pharmacy for premixed syringes of ephedrine, neosynephrine, two STERILE syringes with heavy marcaine and duramorph (for scheduled c/section spinals), two bags of pitocin for the c/sections, four interscalene syringes with epi added to the naropin, etc etc. With just one pharmacy tech on duty, we didn't get our stuff until almost 0900 --- which caused exactly the reaction we wanted. There were several steaming mad surgeons in the CEO's office over this.

The pharmacist held his ground. So we warned him to expect a call at anytime day or night 24/7/365 to admix our pitocin/abx bag for a c/section. And he had better damned well respect the 20 response time that everyone in the OR has to abide by. THIS got his attention. Now he's "researching" the rules.

Just a heads-up, in case your pharmacy department pays attention to the new JCAHO rules.

I've seen this work at one hospital. Every day the pharmacy loads the Pyxis and the anesthesia techs stock the carts with premixed syringes/bags. Ephedrine, phenylephrine, epi, oxytocin, a fent/morph/bupiv concoction for spinals, fent/bupiv mix for CSEs, LA mixes for blocks, norepi bags, etc. I think the prefilled pressor syringes are provided by some outside manufacturer. They also have prepared syringes with things that don't need mixing like atropine and succ, just for convenience.

Honestly it made life a bit easier for us. However there was no rule in place prohibiting us from mixing our own on the fly in the midst of a case.


You said you're mixing pitocin and antibiotics for c-section - I'm curious how many people still give the abx post-delivery these days? Every hospital I've done OB at (n=2 now ) has changed to giving abx pre-incision now, in line with the surgical proph guidelines in use in every non-OB OR.


Oh, and screw JHACO and the horse they rode in on.

 

[dhb]

chief research attendings said that before any neosynephrine is to be given to any patient at ANY time, they want a TEE done.

I can see... i can see... a connection...

 

[Jalopycat]

And with the rising cost of healthcare, exactly who is going to pay for a TEE when neosynephrine is given to a healthy patient?

 

[huktonfonix]

don't ask me how/when this developed, or how this will even work or be validated, but our chief research attendings said that before any neosynephrine is to be given to any patient at ANY time, they want a TEE done. i wonder where the line will start, how long the wait, and where the funds will come for the 20 or so of those that do/read TEEs.

I just assumed that this was a joke.

 

[Gator05]

Interesting that this becomes a hot-button issue as pre-mixed syringes of common anesthesia meds (such as neo and ephedrine) are becoming more available.

For one, I think pharmacy SHOULD be mixing these meds up for us. It's only a few minutes each day, but the time adds up annually when multiplied across an entire group. It's also the pharmacy's responsibility to provide required medications in an appropriate and timely fashion.

Our pharmacy system in the OR is actually quite good, very responsive and helpful. When implemented well, this system works! But it is expensive to do properly, and if the hospital won't do it the right way, the hospital should stay out of our way...

 

[Mofeen]

I just assumed that this was a joke.

Ditto to that

 

[Noyac]

Interesting that this becomes a hot-button issue as pre-mixed syringes of common anesthesia meds (such as neo and ephedrine) are becoming more available.

For one, I think pharmacy SHOULD be mixing these meds up for us. It's only a few minutes each day, but the time adds up annually when multiplied across an entire group. It's also the pharmacy's responsibility to provide required medications in an appropriate and timely fashion.

Our pharmacy system in the OR is actually quite good, very responsive and helpful. When implemented well, this system works! But it is expensive to do properly, and if the hospital won't do it the right way, the hospital should stay out of our way...

The premixing of epidural infusions is fine with me but I'd rather mix my own drugs like neo, spinal meds, epi, dopa, etc. I want to know exactly what I'm giving. If someone else mixes it, I don't know for sure.

I change my spinal dosing frequently depending on the pt and the situation/case. Pharmacy can't keep up.

 

[Monty Python]

I would welcome that rule, rather than bashing it. Pharmacy will get better prepared next time and stock drugs in a refrigerator. Change is good.

Agreed ..... if our hospital pharmacy was properly staffed to support such rules, and was agile enough to immediately respond to our needs. Which it ain't on either count.

 

[Monty Python]

I've seen this work at one hospital. Every day the pharmacy loads the Pyxis and the anesthesia techs stock the carts with premixed syringes/bags. Ephedrine, phenylephrine, epi, oxytocin, a fent/morph/bupiv concoction for spinals, fent/bupiv mix for CSEs, LA mixes for blocks, norepi bags, etc. I think the prefilled pressor syringes are provided by some outside manufacturer. They also have prepared syringes with things that don't need mixing like atropine and succ, just for convenience.

Honestly it made life a bit easier for us. However there was no rule in place prohibiting us from mixing our own on the fly in the midst of a case.


You said you're mixing pitocin and antibiotics for c-section - I'm curious how many people still give the abx post-delivery these days? Every hospital I've done OB at (n=2 now ) has changed to giving abx pre-incision now, in line with the surgical proph guidelines in use in every non-OB OR.


Oh, and screw JHACO and the horse they rode in on.

For scheduled or non-emergent c/sections we give the abx pre-incision. For crash c/sections I add the reconstituted abx to the liter bag containing the xx units of pitocin ordered by the OB.

Which is another reason pre-stocked pitocin bags for c/section won't work. Each of my three OBs orders different amounts of pitocin to hang after the cord is clamped, based on whatever's going through their mind. Having just xx units of pit in a liter bag (with anesthesia prohibited from adding another xx units due to this silly JCAHO rule) just won't cut it.

 

[Monty Python]

I am really glad I don't deal with this crap anymore. A few years ago, when I was still a practicing pharmacist, I tried to follow the JCAHO rules in a similar situation, but on a smaller scale. I knew the anesthiologist well, so he agreed to give it a try. It simply was not a workable situation, for the same reasons you mentioned. I just ignored this JCAHO provision from then on.

That pharmacist is probably still correct on the letter of the JCAHO rules. They are ridiculous and inflexible, but it is what it is. However, drawing a single ingredient up into a syringe isn't reallly admixing, so that should not be an issue. Maybe you can work on this definition with the pharmacist. I consider admixing when you are adding two or more ingredients to an iv bag or syringe, not simply drawing up a med.

One solution that I have seen work, is to have a pharmacist and a tech assigned to the OR in a little OR pharmacy, if they can spare the staff. Some of these things can be pre-made if the pharmacy has the proper clean room setup- that can save a lot of hassle. Basically, JCAHO doesn't want people outside of the pharmacy admixing drugs at all.

Thank you for the post ... I believe this particular post, by someone who has been on both sides of the fence, drives home my point.

 

[jwk]

Two days ago the director of pharmacy came to our preop holding area. He promptly confiscated our bottles of 1% lidocaine to which we had added bicarb (and which is thrown away daily). He said "per new JCAHO rules, only the pharmacy is allowed to admix medications, and it must be done under a sterile hood."

Yesterday the OR schedule went nowhere, since at 0615 every single anesthesiologist and CRNA on duty faxed orders to the pharmacy for premixed syringes of ephedrine, neosynephrine, two STERILE syringes with heavy marcaine and duramorph (for scheduled c/section spinals), two bags of pitocin for the c/sections, four interscalene syringes with epi added to the naropin, etc etc. With just one pharmacy tech on duty, we didn't get our stuff until almost 0900 --- which caused exactly the reaction we wanted. There were several steaming mad surgeons in the CEO's office over this.

The pharmacist held his ground. So we warned him to expect a call at anytime day or night 24/7/365 to admix our pitocin/abx bag for a c/section. And he had better damned well respect the 20 response time that everyone in the OR has to abide by. THIS got his attention. Now he's "researching" the rules.

Just a heads-up, in case your pharmacy department pays attention to the new JCAHO rules.

This is exactly the way to handle pharmacy nazis. If they want to play by the rules, hold them to the exact letter of the law/regs.

Two new things we've heard - one, we're supposed to label all the fluids we hang in the OR with pt name, ID#, time up, etc. NOT!!

The other JCAHO thing we've heard is that we're not supposed to empty urine from a foley bag into an empty irrigation fluid bottle, lest someone pour that bottle of yellow "normal saline" onto the sterile field by mistake. We're supposed to pour it into an open container and hand I guess hand it to the circulator to empty - or maybe just leave it on the floor for the pharmacist to step in later.

 

[Monty Python]

The premixing of epidural infusions is fine with me but I'd rather mix my own drugs like neo, spinal meds, epi, dopa, etc. I want to know exactly what I'm giving. If someone else mixes it, I don't know for sure.

I change my spinal dosing frequently depending on the pt and the situation/case. Pharmacy can't keep up.

.

 

[Monty Python]

... The other JCAHO thing we've heard is that we're not supposed to empty urine from a foley bag into an empty irrigation fluid bottle, lest someone pour that bottle of yellow "normal saline" onto the sterile field by mistake.

I don't know .... some circulators wouldn't notice anything unusual about reaching for another bottle of irrigating solution on the floor under the head of the OR table, next to my feet, versus obtaining it from the warming cabinet. And they wouldn't notice the lack of seal or double cap. The yellow tinge would sail completely past them. Yes, I'm blessed with some Nobel-winning circulators.

I can't wait for next year's JCAHO silliness, if this year's is any indication.

 

[Noyac]

The other JCAHO thing we've heard is that we're not supposed to empty urine from a foley bag into an empty irrigation fluid bottle, lest someone pour that bottle of yellow "normal saline" onto the sterile field by mistake. We're supposed to pour it into an open container and hand I guess hand it to the circulator to empty - or maybe just leave it on the floor for the pharmacist to step in later.

We stopped emptying the foley all together. The pacu nurses hate it and now have convinced the circulators to empty it b/4 leaving the OR. I would hope that if the circulator empties the foley themselves at teh end of the case, they won't confuse it with irrigation fluid.

 

[beezar]

don't ask me how/when this developed, or how this will even work or be validated, but our chief research attendings said that before any neosynephrine is to be given to any patient at ANY time, they want a TEE done. i wonder where the line will start, how long the wait, and where the funds will come for the 20 or so of those that do/read TEEs.

I had a colleague who in general surgery residency at an extremely malignant program was almost fired when one of her attendings who was out to get her complained she didn't draw coags before every EGD (even though a 2nd attending of hers said that was stupid to do).

She ended up going in front of a committee consisting of program directors from various specialties to decide whether she could stay in the program or not. The cardiology program director reprimanded her, saying that coags should be drawn before every invasive procedure, even IV's. Seriously.

So do coags need to be checked before one can even draw coags?

People are stupid.

 

[Noyac]

I had a colleague who in general surgery residency at an extremely malignant program was almost fired when one of her attendings who was out to get her complained she didn't draw coags before every EGD (even though a 2nd attending of hers said that was stupid to do).

She ended up going in front of a committee consisting of program directors from various specialties to decide whether she could stay in the program or not. The cardiology program director reprimanded her, saying that coags should be drawn before every invasive procedure, even IV's. Seriously.

So do coags need to be checked before one can even draw coags?

People are stupid.

 

[oudoc08]

I don't know .... some circulators wouldn't notice anything unusual about reaching for another bottle of irrigating solution on the floor under the head of the OR table, next to my feet, versus obtaining it from the warming cabinet. And they wouldn't notice the lack of seal or double cap. The yellow tinge would sail completely past them. Yes, I'm blessed with some Nobel-winning circulators.

I can't wait for next year's JCAHO silliness, if this year's is any indication.

At least it's sterile. What's the problem? Maybe save some $$$.

 

[rsgillmd]

At least it's sterile. What's the problem? Maybe save some $$$.

You assume it's sterile. Wait until you get the urine of a patient with a UTI.

 

[jwk]

I don't know .... some circulators wouldn't notice anything unusual about reaching for another bottle of irrigating solution on the floor under the head of the OR table, next to my feet, versus obtaining it from the warming cabinet. And they wouldn't notice the lack of seal or double cap. The yellow tinge would sail completely past them. Yes, I'm blessed with some Nobel-winning circulators.

I can't wait for next year's JCAHO silliness, if this year's is any indication.

The unfortunate thing is that some of these regulations come about because some idiot, somewhere, at least once, has made that mistake.

 

[dfk]

Agreed ..... if our hospital pharmacy was properly staffed to support such rules, and was agile enough to immediately respond to our needs. Which it ain't on either count.

agreed. our pharmacy starts late, leaves early, takes way too long of a lunch, and would most likely pull their hair out if they had to mix up ephedrine, neo, any other case-by-case used drug. what a joke IMO. besides, the line would be longer than trying to get into a phish show. so much for on time case starts.

 

[periopdoc]

The mistake was made at a hospital that I am aware of. Basically the usual procedure at this hospital was to collect urine in these bottles and place them on the middle shelf of the circulators cart for postop disposal. As you may or may not have noticed, a slightly dilute urine (say after mannitol admin) looks exactly like the bacitracin solution that the neurosurgeons use to wash out at the conclusion of a crani. Apparently a circulator grabbed a bottle of urine instead of the bottle of baci on the top shelf of the circulators cart.

Of course this bring up a host of questions. Why didn't the circ and scrub confirm what was in the bottle by reading the label, why didn't the circ note that the cap was not sealed etc. However, it seems that the mistake was made at one point and now we all have to pay the price.

I just use the suction containers if I have to empty the bag, but I prefer to let the nurses (in the OR or PACU) deal with it if I have the option.

- pod

 

[dfk]

The mistake was made at a hospital that I am aware of. Basically the usual procedure at this hospital was to collect urine in these bottles and place them on the middle shelf of the circulators cart for postop disposal. As you may or may not have noticed, a slightly dilute urine (say after mannitol admin) looks exactly like the bacitracin solution that the neurosurgeons use to wash out at the conclusion of a crani. Apparently a circulator grabbed a bottle of urine instead of the bottle of baci on the top shelf of the circulators cart.

Of course this bring up a host of questions. Why didn't the circ and scrub confirm what was in the bottle by reading the label, why didn't the circ note that the cap was not sealed etc. However, it seems that the mistake was made at one point and now we all have to pay the price.

I just use the suction containers if I have to empty the bag, but I prefer to let the nurses (in the OR or PACU) deal with it if I have the option.

- pod

during cranes, i just hook up suction tubing from the drain port of the foley to a 3 liter suction container and run via gravity as needed. there's usually no mistaken that it's pee. and the pee stays with me until environmental services comes and wisks it away after we've gone and left.

 

[starsop93]

The other JCAHO thing we've heard is that we're not supposed to empty urine from a foley bag into an empty irrigation fluid bottle, lest someone pour that bottle of yellow "normal saline" onto the sterile field by mistake. We're supposed to pour it into an open container and hand I guess hand it to the circulator to empty - or maybe just leave it on the floor for the pharmacist to step in later.

I also know of a hospital that irrigated a patient's brain with their own urine. It does sound ridiculous, but a brisk diuresis of urine from mannitol looks a lot like saline in the irrigation bottle.

I think that a little "vigilance" from the anesthesiologist and the OR team should prevent this extremely uncommon event from happening, but it's not completely without reason that JCAHO would focus on it.

 

[Impromptu]

Anyone remember the Simpsons clip where Grandpa complains, "my IV is empty and my urine bag is full." to which the nursing home attendant simply switches the lines. Classic mirthmaking.