Dedicated pill crushers/splitters

[sistrmoon, BSN, RN]

We are supposed to be moving toward patient dedicated pill crushers/splitters due to allergies/cross contamination. Totally makes sense to me but I wonder how it will play out in practice because I typically have to search the whole unit for either of these items and sometimes still don't find one. Do you have dedicated crushers/splitters. If not, how is it handled?

[TU RN, DNP, CRNA]

We have them where I work. They're just disposable plastic things with a razor inside that our storeroom/equipment people stock in bulk in the clean supply rooms. Just pop the patient's label on it and stick it in their med drawer. Then when they leave, throw it out.

[sistrmoon, BSN, RN]

That's what ours are like but they are not patient dedicated. There's like one of each for the whole floor.

[Here.I.Stand, BSN, RN]

The last place I worked (an LTACH) had a locked cabinet in each pt room for multi-dose drugs, syringes, anything that needed to be secured. We had a splitter and a crusher in every cabinet.

[Clovery]

We have always had dedicated pill splitters, which are located in the patient's bin in the med room. We pull most of our meds from a Pyxis but some uncommon or over-sized meds are placed in this bin. Most of the patients on our unit have PEG or NG tubes and we have a few Silent Knight crushers in the med rooms. They tried to implement patient specific crushers/splitters (a combination unit with the razor on one side and then you screw down the cap on the other side to crush the pill). This was a huge failure.

They wanted us to keep the crusher/splitter in the patient's room, pull all the meds from the Pyxis, take them to the bedside and crush them there. Most of the nurses tried doing this but the crushers were inadequate. You had to crush the pills one at a time, and they didn't crush it finely, either. Some pills were very difficult if not impossible to crush with the disposable crushers. People were complaining they were going to get carpal tunnel syndrome from the repetitive motion. Another obstacle was all of the patients are on contact isolation and it's really hard to get some pills out of their packaging with gloves on, so this resulted in lots of dropped pills or nurses taking their gloves off in an isolation room. They never removed the Silent Knights from the med rooms, but they stopped stocking the bags. All of these factors resulted in nurses using one pill splitter for all the patients (one we had saved in the med room from a discharged patient). We would crush the pills with the Silent Knights inside their packaging, use a wrapper from an IV flush, use a lab specimen bag. Some people brought in Silent Knight bags from their other facilities. We saved the bag and put it in the patient's bin and reused it until it fell apart. After about two months of this, and us begging for the Silent Knight bags back, they restocked them and went back to just individual pill splitters.

I could see how individual pill crushers/splitters could work if not very many patients need pills crushed, or if they just need to be crushed to be put in apple sauce. But for our unit with patients commonly getting 10+ pills in the morning through an enteral feeding tube, it was totally impractical and their attempt to implement this led to wasted time and less safe practice.

[sistrmoon, BSN, RN]

The last place I worked (an LTACH) had a locked cabinet in each pt room for multi-dose drugs syringes, anything that needed to be secured. We had a splitter and a crusher in every cabinet.[/quote']

I wish we had that! Especially for contact rooms!

[dudette10, MSN, RN]

I love mortar and pestles. Love them. When I need pills crushed, I crush them inside their unit dose packs so that I can still scan the packages bedside. No mess!

For splitting, I carry my own splitter. I clean it with a bleach wipe (very carefully so that I don't cut myself!) after each use.

[nurseprnRN, BSN, RN]

I hear you about the Gtubes, but why not ask your pharmacy to obtain liquid formulations for as many as possible? Yes, they may be more expensive, sometimes. How expensive is your time? How many doses would one hour of your time pay for? I'm serious, get the numbers and crunch them (sorry).

[ChipNurse]

I would bring it up to your manager about there not being enough pill splitters on the floor for each to get their own. She will need to order more in order to implement this practice.

[Clovery]

I hear you about the Gtubes, but why not ask your pharmacy to obtain liquid formulations for as many as possible? Yes, they may be more expensive, sometimes. How expensive is your time? How many doses would one hour of your time pay for? I'm serious, get the numbers and crunch them (sorry).

That's a good idea to get the numbers and try to convince them. I actually spoke to pharmacy last week about getting more liquid formulations, they said they would see what they could do... My main complaint is that calcium and magnesium supplements don't dissolve in water and when we try to administer them they just stick to the sides of the enteral syringe and the patient isn't getting the full dose. And don't even get me started about having to use an 18 gauge needle to poke a hole into capsules like marinol, vitamin D, vitamin A, and nephrocaps and then attempt to squeeze the contents into a cup. Half the time the capsule shoots out of my gloved fingers and is wasted. We also have a patient who gets a cytotoxic/known teratogenic effects cancer med that the nurses have to crush. I asked pharmacy could they get a liquid or formulate it into a liquid under a hood? I described the plumes of powder that often woft up in our faces when crushing pills with the silent knight. They said they couldn't do that and if I was concerned to wear a mask and gloves when I crush it.

[TiffyRN, BSN, PhD]

How expensive is your time? How many doses would one hour of your time pay for? I'm serious, get the numbers and crunch them (sorry).

Well that sounds great in theory, 'cept for one thing. . . I heard a nursing supervisor ask a question one time "How much of the work gets done if you are understaffed?" Her answer; (and some may disagree or pick it apart) None! In a similar way: making the nurse rush around a bit more because he/she had to crush pills rather than use liquids doesn't cost the hospital anything, heck if you stay over it's your patootie because you had poor time management skills.

Maybe focus on literature that explains why liquids are better for enteral tube administration or causes less tube clogging, or more accurate dosing, things like that. Hospitals aren't interested in time saving measures for the nurse unless closely behind that is a cut in staffing.

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[nurseprnRN, BSN, RN]

We also have a patient who gets a cytotoxic/known teratogenic effects cancer med that the nurses have to crush. I asked pharmacy could they get a liquid or formulate it into a liquid under a hood? I described the plumes of powder that often woft up in our faces when crushing pills with the silent knight. They said they couldn't do that and if I was concerned to wear a mask and gloves when I crush it.

The Oncology Nursing Society has standards of practice for this sort of thing, and crushing them outside of a hood is not standard of care. This is an unsafe practice and must not be continued.

https://www.ons.org/practice-resources/clinical-practice/practice-safe-nursing-when-handling-oral-hazardous-drugs