Inpatient Hospice Nurses ..I need your advice on pharmacy situation

[txspadequeenRN, BSN, RN]

oh boy our facility has a problem ..we are a inpatient hospice unit in the dfw area....we have have always had stock drugs iv morphine, ativan, hydromorphone ..the list goes on....we get patinets that require medication as they walk through the door cause they are in pain crisis....we have always medicated them from the stock and gone on wrote the order and got the medication...the triplicates for the drugs are always done after the fact and has always been allowable....just got a fax from texas health care pharm....they are going to take away our stock , require triplicates for every drug up front (they were audited by the texas state board of pharmacy) ..our doctors are not willing to be woke up to fax these triplicates as we have always had standing admission orders ....turn around time from this pharm is hours...sometimes a day...we just cant have patients that come to us for pain management laying in a bed dying with no pain management....my question is to all the nurses working in inpatient hospice only what are the procedures you have in place for ordering medications in your facility...... this situation is driving me nuts cause this will have a huge patient care impact....sickens me...any advise please

[leslie :-D]

it sounds like you folks need to find another pharmacy.

we've had the same one for years, which has a dedicated unit for compounding and customizing agents, specific to our pts.

they are on call/available 24/7.

leslie

[tewdles, RN]

what leslie said....you need another plan.

You are quite correct that your patients cannot be allowed to suffer because of some pharmacy glitch. What must happen is that the pharmacy must have a copy of the signed standing orders on file for the patient. There must be a physician order in place to cover the use of those opioids at the time of use. The pharmacy must have the triplicate before they can send it. You, as an RN do not need a triplicate to obtain the med from the emergency stock. Every hospice that I am aware of has a process to give the RNs access to IV morphine, scop, ativan, valium, etc in emergent situations. Oncall nurses, in particular, must have access to meds to get patients out of crisis...even in the field.

Docs who are managing hospice patients cannot get away from being contacted in the middle of the night on occasion for exacerbation of symptoms, however, faxing of triplicate prescriptions can be accomplished in the morning.

It sounds to me more like the pharmacy has perhaps been lax in their own record keeping and are now over reacting to a ding from their Board. I hope that your medical directors and hospice administration advocate strongly for you and your patients.

[AtlantaRN, RN]

OMG! Isn't that what an emergency box is for?! We have 72 hours to get a written order from the physician. Our pharmacy is 3 miles away and will bring anything 24/7---they are the best. ((They too have run into the DEA giving them fits......for the homecare team-they will give our patients and "emergency" 3 day supply of medication.))

we always have a cadd pump in house and locked up with dilaudid.....

Isn't that what inpatient is for? for emergent care??? If the patients can't get pain relief, they will be in the nearest ER with the costs incurred by your company because pain will be related to their terminal diagnosis........another perfect example of nothing is impossible for the person that doesn't have to do it......you HAVE to have floor stock, and as long as it is documented who got what, I don't see a problem.................

linda

[AtlantaRN, RN]

what leslie said....you need another plan.

You are quite correct that your patients cannot be allowed to suffer because of some pharmacy glitch. What must happen is that the pharmacy must have a copy of the signed standing orders on file for the patient. There must be a physician order in place to cover the use of those opioids at the time of use. The pharmacy must have the triplicate before they can send it. You, as an RN do not need a triplicate to obtain the med from the emergency stock. Every hospice that I am aware of has a process to give the RNs access to IV morphine, scop, ativan, valium, etc in emergent situations. Oncall nurses, in particular, must have access to meds to get patients out of crisis...even in the field.

Docs who are managing hospice patients cannot get away from being contacted in the middle of the night on occasion for exacerbation of symptoms, however, faxing of triplicate prescriptions can be accomplished in the morning.

It sounds to me more like the pharmacy has perhaps been lax in their own record keeping and are now over reacting to a ding from their Board. I hope that your medical directors and hospice administration advocate strongly for you and your patients.

Our home team on call nurses are allowed to come to the IPU in a crisis situation and sign out medication for our home care patients, including a cadd pump. in the emergency box there are an assortment of meds, iv morphine, morphine er, ativan, xanax, valium, roxinol. Home team tries to put an ekit in every home with a small quantity of meds-6 phenergan 25mg suppository, 6 abh 1/25/1 for anxiety/hallucinations, 1 roxinol 20mg/ml-30ml, dulcolax suppository 1, compazine 10mg tablets - 6........and of course there are some that are specific for seizures (iv ativan), and chf (iv and po lasix).

[evolvingrn, BSN, RN]

If people are coming to our IPU in the middle of the night we call and get orders, (we have standing orders) but if they are coming in the middle of the night they have already had our 'emergency team' out to their home and have gotten some meds and need more specific orders. We then fax the order to our pharmacy at some time but once we have the order were free to get the meds from the pyxis

[SoCalRN1970]

agree.. new pharmacy needed.

[tewdles, RN]

I think that part of the problem lies in the fact that many stand alone inpatient hospices are licensed as LTC/SNFs and that changes how their pharmacies operate.

or I could be full of hoo hoo...